Bringing transparency to federal inspections
Tag No.: K0022
Based on observation the facility failed to ensure that exits were clearly identified by appropriate means. Failure to ensure that exits are identified would hinder the safe evacuation of occupants during an emergency. This deficient practice affected 7 patients, staff and visitors on the date of the survey. The facility is licensed for 25 beds and had a census of 7 on the day of the survey.
Findings include:
During the facility tour conducted on February 9, 2015 from 1:00 PM to 2:00 PM, observation of the means of egress leading from the corridor outside the Admissions office to the main entry found no exit sign indicating the path of egress was installed over the smoke compartment doors leading into the lobby.
Actual NFPA standard:
NFPA 101 Chapter 7
7.10.1.2* Exits.
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.
7.7.3
The exit discharge shall be arranged and marked to make clear the direction of egress to a public way. Stairs shall be arranged so as to make clear the direction of egress to a public way. Stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means.
Tag No.: K0025
Based on observation, the facility failed to ensure smoke barrier penetrations were sealed. Failure to seal penetrations in smoke barriers would allow smoke and dangerous gases to pass between smoke compartments affecting egress. This deficient practice affected 7 patients, staff and visitors during the survey. The facility is licensed for 25 beds and had a census of 7 on the day of the survey.
Findings include:
During the facility tour conducted on February 10, 2015 from 9:45 AM to 10:30 AM, above the ceiling inspections of smoke barrier walls found three penetrations in the smoke barrier walls and one in the smoke barrier ceiling.
Specific observation of the smoke barrier wall separating the lobby from the main corridor abutting admissions found one unsealed penetration approximately 3/4" in diameter; observation of the smoke barrier wall separating corridors from the main lobby into the Administration wing found two unsealed penetrations in the wall and one approximately eight inch square opening cut in the ceiling with the patch for the hole dislodged.
Actual NFPA standard:
8.3.2* Continuity.
Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
Exception: A smoke barrier required for an occupied space below an interstitial space shall not be required to extend through the interstitial space, provided that the construction assembly forming the bottom of the interstitial space provides resistance to the passage of smoke equal to that provided by the smoke barrier.
8.3.6 Penetrations and Miscellaneous Openings in Floors and Smoke Barriers.
8.3.6.1
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.
Tag No.: K0038
Based on observation and operational testing, the facility failed to provide readily accessible means of exit access. Failure to allow rapid means of exit access has the potential to impede escape in the event of a fire or other emergency. This deficient practice affected staff and visitors on the date of survey. The facility is licensed for 25 SNF/NF beds and had a census of 7 on the day of survey.
Findings include:
During the facility tour conducted on February 9, 201 from 1:30 M to 3:45 PM, observation and operational testing of the doors to Exposure room 2, Radiology Office and the pre-op room #1 found they were equipped with door locks which required more than one single operation from the egress side.
Specific observations include:
Exposure room 2 - door to toilet/dressing room had a passage lock and slide/throw bolt installed; Door to the main office had a passage lock and deadbolt installed.
Radiology Office - door from main office into corridor abutting Exposure room 2 was equipped with a keyed lock and a slide/throw bolt.
Pre-op room #1 was equipped with a passage hospital lock and a dual keyed deadbolt lock.
Actual NFPA standard:
7.2 MEANS OF EGRESS COMPONENTS
7.2.1.5.4*
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1*: Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
Exception No. 2: The minimum mounting height for the releasing mechanism shall not be applicable to existing installations.
Tag No.: K0051
Based on observation, the facility failed to ensure occupant notification was provided in all sleeping areas. Failure to provide occupant notification in sleeping areas could potentially hinder safe evacuation of all occupants during an emergency. This deficient practice affected staff utilizing the newly added doctor's sleeping lounge across from the existing lounge abutting the ultrasound unit.
Findings include:
During the facility tour conducted on February 9, 2015 from 1:00 PM to 3:45 PM, observation of the newly added second sleeping lounge for doctor's in the central core found it was not equipped with a audible and visible notification device.
Actual NFPA standard:
NFPA 101
19.3.4.3 Notification.
19.3.4.3.1 Occupant Notification.
Occupant notification shall be accomplished automatically in accordance with 9.6.3.
Exception No. 1*: In lieu of audible alarm signals, visible alarm-indicating appliances shall be permitted to be used in critical care areas.
Exception No. 2: Where visual devices have been installed in patient sleeping areas in place of the audible alarm, they shall be permitted where accepted by the authority having jurisdiction.
9.6.3 Occupant Notification.
9.6.3.1
Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.
9.6.3.2
Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
Exception No. 1*: Elevator lobby, hoistway, and associated machine room smoke detectors used solely for elevator recall, and heat detectors used solely for elevator power shutdown, shall not be required to activate the building evacuation alarm if the power supply and installation wiring to these detectors are monitored by the building fire alarm system, and the activation of these detectors results in an audible and visible alarm signal at a constantly attended location.
Exception No. 2*: Smoke detectors used solely for closing dampers or heating, ventilating, and air conditioning system shutdown shall not be required to activate the building evacuation alarm.
Exception No. 3*: Detectors located at doors for the exclusive operation of automatic door release shall not be required to activate the building evacuation alarm.
Exception No. 4: Detectors in accordance with the exception to 22.3.4.3.1 and the exception to 23.3.4.3.1 shall not be required to activate the building evacuation alarm.
Tag No.: K0062
Based on record review and observation, the facility failed to ensure that sprinkler systems were maintained in accordance with NFPA 25 and NFPA 13. Failure to ensure maintenance of fire suppression systems could result in lack of system performance during a fire. This deficient practice affected 7 patients, staff and visitors during the survey. The facility is licensed for 25 beds and had a census of 7 on the survey dates.
Findings include:
1) During record review of the facility conducted on February 9, at approximately 9:45 AM, review of the annual fire sprinkler report found the anti-freeze sprinkler loop was being tested for temperature rather than percentages as required. Further inspection of the records found the concentration of Propylene Glycol anti-freeze in the loop located in the Mechanical Room was marked at -34 degrees F (52 percent).
Inspection of the riser tags confirmed the findings of the concentrations shown on the inspection report.
2) During the facility tour conducted on February 9, 2015 from 12:30 PM to 3:45 PM, observation of the General Storage room and the electrical closet located inside, found three sprinkler heads which had been painted.
3) During the facility tour conducted on February 10, 2015 from 1:00 PM to 2:00 PM, observation of the exit overhangs located on the south, northwest and northeast exits of the skilled nursing section of the facility found that these exits were equipped with sprinkler system piping. Further inspection found these overhangs measured over 48 inches and two of the three pipes had the heads removed and a plug placed into the elbow. Further investigation indicated that this piping may no longer be in service.
4) During record review conducted on February 9, 2015 at approximately 9:45 AM, review of the annual fire sprinkler inspection report found the notation for a potential need of added sprinkler coverage at the added wall in Central Supply (Sterile Storage).
Actual NFPA standard:
Finding 1
NFPA 13
4-5 Antifreeze Systems.
4-5.1* Where Used.
The use of antifreeze solutions shall be in conformity with state and local health regulations.
NFPA 25
2-3.4* Antifreeze Systems.
The freezing point of solutions in antifreeze shall be tested annually by measuring the specific gravity with a hydrometer or refractometer and adjusting the solutions if necessary. Solutions shall be in accordance with Tables 2-3.4(a) and (b).
The use of antifreeze solutions shall be in accordance with any state or local health regulations. [See Table 2-3.4(b).]
Refer to NFPA anti-freeze update:
http://www.nfpa.org/antifreeze
Finding 2
NFPA 25
2-2 Inspection.
2-2.1 Sprinklers.
2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1*: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.
Finding 3&4
NFPA 13
1-6 Level of Protection.
1-6.1
A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.
Exception: This requirement shall not apply where specific sections of this standard permit the omission of sprinklers.
NFPA 13
5-13.8* Exterior Roofs or Canopies.
5-13.8.1
Sprinklers shall be installed under exterior roofs or canopies exceeding 4 ft (1.2 m) in width.
Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction.
NFPA 13
5-5.3 Sprinkler Spacing.
5-5.3.1 Maximum Distance Between Sprinklers.
The maximum distance permitted between sprinklers shall be based on the centerline distance between sprinklers on the branch line or on adjacent branch lines. The maximum distance shall be measured along the slope of the ceiling. The maximum distance permitted between sprinklers shall comply with the value indicated in the section for each type or style of sprinkler.
5-5.3.2 Maximum Distance From Walls.
The distance from sprinklers to walls shall not exceed one-half of the allowable maximum distance between sprinklers. The distance from the wall to the sprinkler shall be measured perpendicular to the wall.
5-5.3.3 Minimum Distance from Walls.
The minimum distance permitted between a sprinkler and the wall shall comply with the value indicated in the section for each type or style of sprinkler. The distance from the wall to the sprinkler shall be measured perpendicular to the wall.
Tag No.: K0130
Based on observation of the Specialty Clinic associated with the hospital, the following findings were noted during the tour of the building conducted on February 10, 2015:
Finding 1
During the facility tour conducted on February 10, 2015 from 9:45 AM to 11:30 AM, observation and operational testing of the door from the lower floor/basement offices to the main floor patient/treatment area of the Specialty Clinic found the door at the bottom of the stairs was not equipped with a self-closing device.
Actual NFPA standard:
39.3 PROTECTION
39.3.1 Protection of Vertical Openings.
39.3.1.1
Any vertical opening shall be enclosed or protected in accordance with 8.2.5.
Exception No. 1: Unenclosed vertical openings in accordance with 8.2.5.8 shall be permitted.
Exception No. 2: Exit access stairs shall be permitted to be unenclosed in two-story single-tenant spaces that are provided with a single exit in accordance with Exception No. 4 to 39.2.4.2.
Exception No. 3: In buildings protected throughout by an approved automatic sprinkler system in accordance with Section 9.7, unprotected vertical openings shall be permitted. This exception shall be permitted only where no unprotected vertical opening serves as any part of any required means of egress and all required exits consist of outside stairs in accordance with 7.2.2, smokeproof enclosures in accordance with 7.2.3, or horizontal exits in accordance with 7.2.4.
8.2.5.4*
The fire resistance rating for the enclosure of floor openings shall be not less than as follows (see 7.1.3.2.1 for enclosure of exits):
(1) Enclosures connecting four stories or more in new construction - 2-hour fire barriers
(2) Other enclosures in new construction - 1-hour fire barriers
(3) Existing enclosures in existing buildings - 1/2-hour fire barriers
(4) As specified in Chapter 26 for lodging and rooming houses, in Chapter 28 for new hotels, and in Chapter 30 for new apartment buildings
Finding 2
During the facility tour conducted on February 10, 2015 from 9:45 AM to 11:30 AM, observation and operational testing of the battery back-up exit signs located in the Specialty Clinic found that four of the five installed signs had dead batteries.
Actual NFPA standard:
NFPA 101 Chapter 7
7.10.9 Testing and Maintenance.
7.10.9.1 Inspection.
Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.
7.10.9.2 Testing.
Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.
Finding 3
During the facility tour conducted on February 10, 2015 from 9:45 AM to 11:30 AM, observation of the fire extinguisher installed in the hall of the main floor found it was installed at approximately 61 inches from the floor.
Actual NFPA standard:
NFPA 10
1-6.10
Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).
Tag No.: K0211
Based on observation the facility failed to ensure that flammable liquids were protected from an ignition source. Failure to ensure that alcohol based hand rub dispensers are not installed above or near an ignition source could expose occupants to a fire and/or smoke environment. This deficient practice affected 7 patients, staff and visitors on the date of the survey. The facility is licensed for 25 beds and had a census of 7 on the day of the survey.
Findings include:
During the facility tour conducted on February 9, 2015 from 1:30 PM to 2:30 PM, observation of the Human Resources Manager office found an alcohol based hand rub dispenser installed over an electrical outlet.
Actual NFPA standard:
19.3.2.7 of the 2000 edition of the LSC as amended:
·Where dispensers are installed in a corridor, the corridor shall have a minimum width of 6 ft (1.8m).
·The maximum individual dispenser fluid capacity shall be: -0.3 gallons (1.2 liters) for dispensers
·in rooms, corridors, and areas open to corridors. -0.5 gallons (2.0 liters) for dispensers in suites of rooms.
·The dispensers shall have a minimum horizontal spacing of 4 ft (1.2m) from each other.
·Not more than an aggregate 10 gallons (37.8 liters) of ABHR solution shall be in use in a single smoke compartment outside of a storage cabinet.
·Storage of quantities greater than 5 gallons (18.9 liters) in a single smoke compartment shall meet the requirements of NFPA 30, Flammable and Combustible Liquids Code.
·The dispensers shall not be installed over or directly adjacent to an ignition source.
·In locations with carpeted floor coverings, dispensers installed directly over carpeted surfaces shall be permitted only in sprinklered smoke compartments.