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Based on observation, the facility failed to protect corridor openings by not ensuring all corridor doors close and latch in accordance with NFPA 101, 2000 Edition, Sections 18.3.6.3.2, 18.3.6.3.3 and Annex 18.3.6.3.3.A. These deficiencies could affect 1 of 2 smoke compartments.

Findings include:

1. During an observation on 8/3/15 at 2:00 p.m., the corridor door to the Imaging Service Manager's office was exercised. The door had a wedge beneath the door and the manager was not in ear or eye sight of the wedged door.¹

2. During an observation on 8/3/15 at 2:05 p.m., the corridor door to the ultrasound imaging room failed to latch when exercised on three different tries. The self-closing device failed to latch the door on its own.²

¹ NFPA 101, 2000 Edition, Section 18.3.6.3.3; Hold-open devices that release when the door is pushed or pulled shall be permitted. Annex A.18.3.6.3.3 Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

² NFPA 101, 2000 Edition, Section 18.3.6.3.2; Doors shall be provided with positive latching hardware. Roller latches shall be prohibited.
Exception: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.

Based on observation, the facility failed to ensure that penetrations in smoke barriers were adequately protected per NFPA 101, 2000 Edition, Sections 8.3.2. and 8.2.3.2.4.2. This deficiency would affect 2 of 5 smoke compartments.

Findings include:

During an observation on 8/4/15 at 7:20 a.m., the smoke barrier in the attic above LTC above room 204(LTC) was inspected. There were two penetrations in the barrier which were not sealed.¹ ² One being an electrical conduit (1 and 1/2 inch in size) and the remainder a batch of television cable.

¹ NFPA 101, 2000 Edition, Section 8.3.2; 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.

² NFPA 101, 2000 Edition, Section 8.2.3.2.4.2; Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire 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 fire barrier, the sleeve shall be solidly set in the fire 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 fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) 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 fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observation and interview, the facility failed to conduct the 90 minute (1 1/2 hour) annual tests on the battery powered emergency light fixtures in the surgical suites, Fire Alarm Control Panel room, generator room, laboratory and other places where emergency lights were installed in accordance with NFPA 101, 2000 Edition, Section 7.9.3.¹ These deficiencies could affect 2 of 5 smoke compartments.

Findings include:

Review of the facilities emergency lighting documentation indicated that the most recent annual battery test was done on 5/15/14. An annual test should have occurred within one year plus 30 days or 6/14/15 at a maximum.

During an interview on 8/3/15 at 10:30 a.m., staff member A, maintenance director, stated that a preventative maintenance report had not come up for that task. He stated that they would have to ensure that it was created in the computer report system to come up each year, but had yet to be completed.

Observations within the facility over the two days of the survey revealed that there were a number of emergency lighting units in surgery, recovery, Fire Alarm Control Panel room, generator room and other portions of the building.

¹ NFPA 101, 2000 Edition, Section 7.9.3; 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 1 1/2 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.

Based on observation, the facility failed to provide a complete sprinkler system free of obstructions for complete sprinkler pattern coverage in accordance with NFPA 13, 1999 Edition, Section 5-6.5.2.1 and NFPA 101, 2000 Edition, Section 19.1.6.2. The deficiency could affect 2 of 5 smoke compartments.

Findings include:

1. During an observation on 8/3/15 at 11:38 a.m., the med gas/oxygen storeroom was not fully sprinkled. The original room for oxygen storage was approximately six feet by eight feet. There was an addition to the original storeroom made approximately two years ago which added an additional eight feet wide by fourteen feet long area. The new portion was not properly covered by the automatic sprinkler system.¹

2. During an observation on 8/3/15 at 12:45 p.m., the materials management storage area was inspected. The florescent lighting units had been hung between sprinkler heads on the ceiling, but several areas of the storeroom were without complete sprinkler coverage due to the lighting units blocking spray pattern for the sprinkler heads. The lights were mounted within 18 inches of the sprinkler deflectors.

¹ NFPA 101, 2000 Edition, Section 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Exception*: Any building of Type I(443), Type I(332), Type II(222), or Type II(111) construction shall be permitted to include roofing systems involving combustible supports, decking, or roofing, provided that the following criteria are met:
(a) The roof covering meets Class C requirements in accordance with NFPA 256, Standard Methods of Fire Tests of Roof Coverings.
(b) The roof is separated from all occupied portions of the building by a noncombustible floor assembly that includes not less than 21/2 in. (6.4 cm) of concrete or gypsum fill.
(c) The attic or other space is either unoccupied or protected throughout by an approved automatic sprinkler system.
Table 19.1.6.2 Construction Type Limitations

Construction Type Stories
1 2 3 4 or More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)

² NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-6.5.2.1, Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with this section. Regardless of the rules of this section, solid continuous obstructions shall meet the requirements of 5-6.5.1.2.

Based on observation and interview, the facility failed to maintain components of the sprinkler system in accordance with NFPA 13, 1998 Edition, Section 5-1.1. The deficiency could affect 1 of 2 smoke compartments.

Findings included:

During an observation on 8/3/15 at 2:10 p.m., a ceiling tile was missing at the entrance area near the Emergency Room.

During an interview on 8/4/15 at 9:30 a.m., staff member A, maintenance director, stated that his maintenance staff had searched for a water shut off valve approximately one month earlier, and neglected to put the ceiling tile back in place.

¹ NFPA 13 Standard for the Installation of Sprinkler Systems 1999 Edition, Section 5-1.1; The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5-6.4.1, 5-7.4.1, 5-8.4.1, 5-9.4.1, 5-10.4.1, and 5-11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.

Based on observation, the facility failed to place portable fire extinguishers at proper height of 60 inches (5 feet) per NFPA 10, Section 1-6.10. This deficiency could affect 1 of 1 mechanical penthouse smoke compartment.

Findings include:

During an observation on 8/3/15 at 2:35 p.m., the portable extinguisher next to the
access ladder from the mechanical penthouse was inspected. It was measured to be 72 inches to the top of the extinguisher.¹

¹ NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 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).

Based on observation and interview, the facility failed to meet the medical gas storage requirements in accordance with NFPA 50, 1996 Edition, Sections 1-3 and 4-2.1 and NFPA 99, 1999 Edition, Section 4-3.1.1.1. These deficiencies could affect 2 of 5 smoke compartments.

Findings include:

1. During an observations on 8/3/15 at 11:38 a.m., the east side medical gas storeroom was inspected. The amount of stored oxygen would qualify the area as a bulk oxygen system as it exceeded 20,000 cubic feet. The following deficiencies were noted:
a) There were several, unsecured helium cylinders in the storeroom.¹
b) There was no annual inspection of the bulk oxygen system performed by a qualified representative or properly trained employee of the facility.²

During an interview on 8/3/15 at noon, with staff member A, maintenance director, stated an annual review had not been done of the bulk oxygen system.³

¹ NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 4-3.1.1.1; (Cylinder and Container Management), Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

² NFPA 50 Standard for Bulk Oxygen Systems at Consumer Sites, 1996 Edition, Section 1-3 Definitions; For the purpose of the standard, the following terms are defined as follows:Bulk Oxygen System. A bulk oxygen system is an assembly of equipment, such as oxygen storage containers, pressure regulators, safety devices, vaporizers, manifolds, and interconnecting piping, that has a storage capacity of more than 20,000 ft3 (566 m3) of oxygen (NTP) including unconnected reserves on hand at the site. The bulk oxygen system terminates at the point where oxygen at service pressure first enters the supply line. The oxygen containers may be stationary or movable, and the oxygen may be stored as gas or liquid.

³ NFPA 50, 1996 Edition, Section 4-2.1; Each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

Based on observations, record review and interview, the facility failed to ensure that fire dampers were exercised once in four years time per NFPA 90A, 1999 Edition, Section 3-4.7¹. These deficiencies could effect 5 of 5 smoke compartments.

Findings include:

Review of facility records for smoke and fire dampers was completed on 8/3/15 at 10:20 a.m. The records showed dampers were being tested, but records lacked which dampers had been tested as they had not been numbered or indicated on a map as to location. It was impossible to determine which had been tested and if the total amount had been completed within four years time.

During an interview on 8/3/15 at 10:25 a.m., staff member A, maintenance director, indicated that they were testing dampers on a regular basis during all monthly fire drills. There was no documentation of which ones were tested and where in the facility they were located.

During observations on 8/4/15 at 8:37 a.m., fusible link dampers were noted to be in the attic between the long term care (LTC) building and the critical access hospital (CAH). These were located above rooms 204 and 210 of the long term care.

¹ NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems,1999 Edition, Section 3-4.7 Maintenance, At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.
Note: Hospitals can qualify for a six year damper test interval per CMS S&C Policy S&C-10-04-LSC Waiver to Allow Hospitals to Use the NFPA 6-Year Damper Testing Interval, Issued 10/30/09.

Based on observations, record review and interview, the facility failed to ensure that fire dampers were exercised once in four years time per NFPA 90A, 1999 Edition, Section 3-4.7¹. These deficiency could effect 2 of 2 smoke compartments.

Findings include:

Review of facility records for smoke and fire dampers was completed on 8/3/15 at 10:20 a.m. The records show the dampers were being tested, but lacked specifics on which dampers had been tested as they had not been numbered or indicated on a map as to their location. It was impossible to determine which had been tested and if the total amount had been completed within a four years time.

During an interview on 8/3/15 at 10:25 a.m., staff member A, maintenance director, indicated that they were testing dampers on a regular basis during all monthly fire drills. There was no documentation of which ones were tested and where in the facility they were located.

During observations on 8/4/15 at 8:37 a.m., fusible link dampers were noted to be in the attic between the long term care (LTC) building and the CAH. These were located above rooms 204 and 210 of the LTC.

¹ NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems,1999 Edition, Section 3-4.7 Maintenance; At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.
Note: Hospitals can qualify for a six year damper test interval per CMS S&C Policy S&C-10-04-LSC Waiver to Allow Hospitals to Use the NFPA 6-Year Damper Testing Interval, Issued 10/30/09.

Based on observation and interview, the facility failed to assure that the burner areas in natural gas dryers were maintained clear of any combustible material that could ignite in accordance with NFPA 54, 1999 Edition, Section 5.2.2.¹ This deficiency would affect 1 of 5 smoke compartments.

The findings include:

During an observation on 8/3/15 at 1:00 p.m., the enclosed room behind the gas dryers in laundry were inspected. The natural gas dryers had accumulations of lint in the burner areas of each dryer that had the potential to ignite. There were also accumulations of lint on the dryer exhaust tubes, walls and floor of the room.

During an interview on 8/3/15 at 1:00 p.m., staff member B, maintenance staff, explained that the room behind the gas dryers were being cleaned once per month, and that it may not be often enough to eliminate lint buildup.

¹ NFPA 54 National Fuel Gas Code, 1999 Edition, Section 5.2.2; natural gas fueled equipment, including Type 2 clothes dryers, shall be installed with clearances from combustible material (materials adjacent to or in contact with heat-producing appliances, vent connectors or gas vents that are capable of being ignited and burned) so that their operation will not create a hazard to persons or property.

Based on observation and interview, the facility failed to maintain the electrical system and/or its components in accordance with the NFPA 70, 1999 Edition, Articles 305-2(b) and 400-8. These deficiencies could affect 1 of 5 smoke compartments.

Findings include:

During an observation on 8/3/15 at 1:10 p.m., there was an orange extension cord in-use to the chemistry analyzer in the lab. Extension cords may not be used in the place of permanent wiring.¹ ²

¹ NFPA 70 National Electrical Code, 1999 Edition, Article 305-2(b); All Wiring Installations (a) Other Articles. Except as specifically modified in this article, all other requirements of this Code for permanent wiring shall apply to temporary wiring installations.
(b) Approval. Temporary wiring methods shall be acceptable only if approved based on the conditions of use and any special requirements of the temporary installation.

² NFPA 70, 1999 Edition, Article 400-8. Uses Not Permitted; Unless specifically permitted in Article 400-7, flexible cords and cables shall not be used for the following:
1. As a substitute for the fixed wiring of a structure
2. Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
3. Where run through doorways, windows, or similar openings
4. Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
5. Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
6. Where installed in raceways, except as otherwise permitted in this Code

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC, and NFPA 70, 1999 Edition, Article 305-2(b). These deficiencies could affect 2 of 2 smoke compartments.

Findings include:

1. During an observation on 8/3/15 at 2:30 p.m., there was a multi-plug adaptor found in-use in the Day Surgery manager's office.¹

2. During an observation on 8/3/15 at 3:00 p.m., there was an extension cord found in-use in the Financial Assistance manager's office.¹

3. During an observation on 8/3/15 at 3:17 p.m., there was a refrigerator plugged into a power strip in the Comptroller's office.²

¹ NFPA 70 National Electrical Code, 1999 Edition, Article 305-2(b); All Wiring Installations (a) Other Articles. Except as specifically modified in this article, all other requirements of this Code for permanent wiring shall apply to temporary wiring installations.
(b) Approval. Temporary wiring methods shall be acceptable only if approved based on the conditions of use and any special requirements of the temporary installation.

² CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

Based on observation, the facility failed to protect corridor openings by not ensuring all corridor doors close and latch in accordance with NFPA 101, 2000 Edition, Sections 18.3.6.3.2, 18.3.6.3.3 and Annex 18.3.6.3.3.A. These deficiencies could affect 1 of 2 smoke compartments.

Findings include:

1. During an observation on 8/3/15 at 2:00 p.m., the corridor door to the Imaging Service Manager's office was exercised. The door had a wedge beneath the door and the manager was not in ear or eye sight of the wedged door.¹

2. During an observation on 8/3/15 at 2:05 p.m., the corridor door to the ultrasound imaging room failed to latch when exercised on three different tries. The self-closing device failed to latch the door on its own.²

¹ NFPA 101, 2000 Edition, Section 18.3.6.3.3; Hold-open devices that release when the door is pushed or pulled shall be permitted. Annex A.18.3.6.3.3 Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

² NFPA 101, 2000 Edition, Section 18.3.6.3.2; Doors shall be provided with positive latching hardware. Roller latches shall be prohibited.
Exception: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.

Based on observation, the facility failed to ensure that penetrations in smoke barriers were adequately protected per NFPA 101, 2000 Edition, Sections 8.3.2. and 8.2.3.2.4.2. This deficiency would affect 2 of 5 smoke compartments.

Findings include:

During an observation on 8/4/15 at 7:20 a.m., the smoke barrier in the attic above LTC above room 204(LTC) was inspected. There were two penetrations in the barrier which were not sealed.¹ ² One being an electrical conduit (1 and 1/2 inch in size) and the remainder a batch of television cable.

¹ NFPA 101, 2000 Edition, Section 8.3.2; 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.

² NFPA 101, 2000 Edition, Section 8.2.3.2.4.2; Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire 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 fire barrier, the sleeve shall be solidly set in the fire 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 fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) 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 fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observation and interview, the facility failed to conduct the 90 minute (1 1/2 hour) annual tests on the battery powered emergency light fixtures in the surgical suites, Fire Alarm Control Panel room, generator room, laboratory and other places where emergency lights were installed in accordance with NFPA 101, 2000 Edition, Section 7.9.3.¹ These deficiencies could affect 2 of 5 smoke compartments.

Findings include:

Review of the facilities emergency lighting documentation indicated that the most recent annual battery test was done on 5/15/14. An annual test should have occurred within one year plus 30 days or 6/14/15 at a maximum.

During an interview on 8/3/15 at 10:30 a.m., staff member A, maintenance director, stated that a preventative maintenance report had not come up for that task. He stated that they would have to ensure that it was created in the computer report system to come up each year, but had yet to be completed.

Observations within the facility over the two days of the survey revealed that there were a number of emergency lighting units in surgery, recovery, Fire Alarm Control Panel room, generator room and other portions of the building.

¹ NFPA 101, 2000 Edition, Section 7.9.3; 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 1 1/2 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.

Based on observation, the facility failed to provide a complete sprinkler system free of obstructions for complete sprinkler pattern coverage in accordance with NFPA 13, 1999 Edition, Section 5-6.5.2.1 and NFPA 101, 2000 Edition, Section 19.1.6.2. The deficiency could affect 2 of 5 smoke compartments.

Findings include:

1. During an observation on 8/3/15 at 11:38 a.m., the med gas/oxygen storeroom was not fully sprinkled. The original room for oxygen storage was approximately six feet by eight feet. There was an addition to the original storeroom made approximately two years ago which added an additional eight feet wide by fourteen feet long area. The new portion was not properly covered by the automatic sprinkler system.¹

2. During an observation on 8/3/15 at 12:45 p.m., the materials management storage area was inspected. The florescent lighting units had been hung between sprinkler heads on the ceiling, but several areas of the storeroom were without complete sprinkler coverage due to the lighting units blocking spray pattern for the sprinkler heads. The lights were mounted within 18 inches of the sprinkler deflectors.

¹ NFPA 101, 2000 Edition, Section 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Exception*: Any building of Type I(443), Type I(332), Type II(222), or Type II(111) construction shall be permitted to include roofing systems involving combustible supports, decking, or roofing, provided that the following criteria are met:
(a) The roof covering meets Class C requirements in accordance with NFPA 256, Standard Methods of Fire Tests of Roof Coverings.
(b) The roof is separated from all occupied portions of the building by a noncombustible floor assembly that includes not less than 21/2 in. (6.4 cm) of concrete or gypsum fill.
(c) The attic or other space is either unoccupied or protected throughout by an approved automatic sprinkler system.
Table 19.1.6.2 Construction Type Limitations

Construction Type Stories
1 2 3 4 or More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)

² NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-6.5.2.1, Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with this section. Regardless of the rules of this section, solid continuous obstructions shall meet the requirements of 5-6.5.1.2.

Based on observation and interview, the facility failed to maintain components of the sprinkler system in accordance with NFPA 13, 1998 Edition, Section 5-1.1. The deficiency could affect 1 of 2 smoke compartments.

Findings included:

During an observation on 8/3/15 at 2:10 p.m., a ceiling tile was missing at the entrance area near the Emergency Room.

During an interview on 8/4/15 at 9:30 a.m., staff member A, maintenance director, stated that his maintenance staff had searched for a water shut off valve approximately one month earlier, and neglected to put the ceiling tile back in place.

¹ NFPA 13 Standard for the Installation of Sprinkler Systems 1999 Edition, Section 5-1.1; The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5-6.4.1, 5-7.4.1, 5-8.4.1, 5-9.4.1, 5-10.4.1, and 5-11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.

Based on observation, the facility failed to place portable fire extinguishers at proper height of 60 inches (5 feet) per NFPA 10, Section 1-6.10. This deficiency could affect 1 of 1 mechanical penthouse smoke compartment.

Findings include:

During an observation on 8/3/15 at 2:35 p.m., the portable extinguisher next to the
access ladder from the mechanical penthouse was inspected. It was measured to be 72 inches to the top of the extinguisher.¹

¹ NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 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).

Based on observation and interview, the facility failed to meet the medical gas storage requirements in accordance with NFPA 50, 1996 Edition, Sections 1-3 and 4-2.1 and NFPA 99, 1999 Edition, Section 4-3.1.1.1. These deficiencies could affect 2 of 5 smoke compartments.

Findings include:

1. During an observations on 8/3/15 at 11:38 a.m., the east side medical gas storeroom was inspected. The amount of stored oxygen would qualify the area as a bulk oxygen system as it exceeded 20,000 cubic feet. The following deficiencies were noted:
a) There were several, unsecured helium cylinders in the storeroom.¹
b) There was no annual inspection of the bulk oxygen system performed by a qualified representative or properly trained employee of the facility.²

During an interview on 8/3/15 at noon, with staff member A, maintenance director, stated an annual review had not been done of the bulk oxygen system.³

¹ NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 4-3.1.1.1; (Cylinder and Container Management), Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

² NFPA 50 Standard for Bulk Oxygen Systems at Consumer Sites, 1996 Edition, Section 1-3 Definitions; For the purpose of the standard, the following terms are defined as follows:Bulk Oxygen System. A bulk oxygen system is an assembly of equipment, such as oxygen storage containers, pressure regulators, safety devices, vaporizers, manifolds, and interconnecting piping, that has a storage capacity of more than 20,000 ft3 (566 m3) of oxygen (NTP) including unconnected reserves on hand at the site. The bulk oxygen system terminates at the point where oxygen at service pressure first enters the supply line. The oxygen containers may be stationary or movable, and the oxygen may be stored as gas or liquid.

³ NFPA 50, 1996 Edition, Section 4-2.1; Each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

Based on observations, record review and interview, the facility failed to ensure that fire dampers were exercised once in four years time per NFPA 90A, 1999 Edition, Section 3-4.7¹. These deficiencies could effect 5 of 5 smoke compartments.

Findings include:

Review of facility records for smoke and fire dampers was completed on 8/3/15 at 10:20 a.m. The records showed dampers were being tested, but records lacked which dampers had been tested as they had not been numbered or indicated on a map as to location. It was impossible to determine which had been tested and if the total amount had been completed within four years time.

During an interview on 8/3/15 at 10:25 a.m., staff member A, maintenance director, indicated that they were testing dampers on a regular basis during all monthly fire drills. There was no documentation of which ones were tested and where in the facility they were located.

During observations on 8/4/15 at 8:37 a.m., fusible link dampers were noted to be in the attic between the long term care (LTC) building and the critical access hospital (CAH). These were located above rooms 204 and 210 of the long term care.

¹ NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems,1999 Edition, Section 3-4.7 Maintenance, At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.
Note: Hospitals can qualify for a six year damper test interval per CMS S&C Policy S&C-10-04-LSC Waiver to Allow Hospitals to Use the NFPA 6-Year Damper Testing Interval, Issued 10/30/09.

Based on observations, record review and interview, the facility failed to ensure that fire dampers were exercised once in four years time per NFPA 90A, 1999 Edition, Section 3-4.7¹. These deficiency could effect 2 of 2 smoke compartments.

Findings include:

Review of facility records for smoke and fire dampers was completed on 8/3/15 at 10:20 a.m. The records show the dampers were being tested, but lacked specifics on which dampers had been tested as they had not been numbered or indicated on a map as to their location. It was impossible to determine which had been tested and if the total amount had been completed within a four years time.

During an interview on 8/3/15 at 10:25 a.m., staff member A, maintenance director, indicated that they were testing dampers on a regular basis during all monthly fire drills. There was no documentation of which ones were tested and where in the facility they were located.

During observations on 8/4/15 at 8:37 a.m., fusible link dampers were noted to be in the attic between the long term care (LTC) building and the CAH. These were located above rooms 204 and 210 of the LTC.

¹ NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems,1999 Edition, Section 3-4.7 Maintenance; At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.
Note: Hospitals can qualify for a six year damper test interval per CMS S&C Policy S&C-10-04-LSC Waiver to Allow Hospitals to Use the NFPA 6-Year Damper Testing Interval, Issued 10/30/09.

Based on observation and interview, the facility failed to assure that the burner areas in natural gas dryers were maintained clear of any combustible material that could ignite in accordance with NFPA 54, 1999 Edition, Section 5.2.2.¹ This deficiency would affect 1 of 5 smoke compartments.

The findings include:

During an observation on 8/3/15 at 1:00 p.m., the enclosed room behind the gas dryers in laundry were inspected. The natural gas dryers had accumulations of lint in the burner areas of each dryer that had the potential to ignite. There were also accumulations of lint on the dryer exhaust tubes, walls and floor of the room.

During an interview on 8/3/15 at 1:00 p.m., staff member B, maintenance staff, explained that the room behind the gas dryers were being cleaned once per month, and that it may not be often enough to eliminate lint buildup.

¹ NFPA 54 National Fuel Gas Code, 1999 Edition, Section 5.2.2; natural gas fueled equipment, including Type 2 clothes dryers, shall be installed with clearances from combustible material (materials adjacent to or in contact with heat-producing appliances, vent connectors or gas vents that are capable of being ignited and burned) so that their operation will not create a hazard to persons or property.

Based on observation and interview, the facility failed to maintain the electrical system and/or its components in accordance with the NFPA 70, 1999 Edition, Articles 305-2(b) and 400-8. These deficiencies could affect 1 of 5 smoke compartments.

Findings include:

During an observation on 8/3/15 at 1:10 p.m., there was an orange extension cord in-use to the chemistry analyzer in the lab. Extension cords may not be used in the place of permanent wiring.¹ ²

¹ NFPA 70 National Electrical Code, 1999 Edition, Article 305-2(b); All Wiring Installations (a) Other Articles. Except as specifically modified in this article, all other requirements of this Code for permanent wiring shall apply to temporary wiring installations.
(b) Approval. Temporary wiring methods shall be acceptable only if approved based on the conditions of use and any special requirements of the temporary installation.

² NFPA 70, 1999 Edition, Article 400-8. Uses Not Permitted; Unless specifically permitted in Article 400-7, flexible cords and cables shall not be used for the following:
1. As a substitute for the fixed wiring of a structure
2. Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
3. Where run through doorways, windows, or similar openings
4. Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
5. Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
6. Where installed in raceways, except as otherwise permitted in this Code

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC, and NFPA 70, 1999 Edition, Article 305-2(b). These deficiencies could affect 2 of 2 smoke compartments.

Findings include:

1. During an observation on 8/3/15 at 2:30 p.m., there was a multi-plug adaptor found in-use in the Day Surgery manager's office.¹

2. During an observation on 8/3/15 at 3:00 p.m., there was an extension cord found in-use in the Financial Assistance manager's office.¹

3. During an observation on 8/3/15 at 3:17 p.m., there was a refrigerator plugged into a power strip in the Comptroller's office.²

¹ NFPA 70 National Electrical Code, 1999 Edition, Article 305-2(b); All Wiring Installations (a) Other Articles. Except as specifically modified in this article, all other requirements of this Code for permanent wiring shall apply to temporary wiring installations.
(b) Approval. Temporary wiring methods shall be acceptable only if approved based on the conditions of use and any special requirements of the temporary installation.

² CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.