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Based on observation and interview the facility failed to assure that fire doors are properly maintained to close and latch. This deficient practice may cause fire/smoke to travel to an adjacent smoke zone in the building. This will affect 2 out of 16 smoke zones in the building. This facility has a capacity of 222 with a census of 98, 110, 120 and 125 on each day of the survey.

Findings include:

During the tour between 7/18/11 8:00 AM to 7/22/11 5:00 PM it was found that the 1.5 hour double fire doors to the ambulance bay did not latch when released from the magnetic hold open devices.

Staff M was present and aware of the finding.

NFPA Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2

Based on observation and interview the facility failed to assure that smoke barrier walls are properly sealed. This deficient practice may cause smoke/fire to travel to adjacent rooms or corridors. This may affect 1 out of 16 smoke zones in the building. This facility has a capacity of 222 with a census of 98, 110, 120 and 125 on each day of the survey.

Findings include:

During the tour between 7/18/11 8:00 AM to 7/22/11 5:00 PM it was found that the Communications closet smoke walls has 3 openings through I.T. 4" conduit that has not been sealed with fire caulk, and a 1" hole through sheetrock that was not filled with a utility conduit or fire caulk.

Staff M2 was present and acknowledged the finding.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

NFPA Standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3

Based on observation and interview the facility failed to assure that the sprinkler system is properly maintained. This deficient practice may cause smoke/fire to travel into the ceiling area. This will affect 1 out of 16 smoke zones in the building. This facility has a capacity of 222 with a census of 98, 110, 120 and 125 on each day of the survey.

Findings include:

During the tour between 7/18/11 8:00 AM to 7/22/11 5:00 PM it was found that the escutcheon was missing from the following:

1.) The sprinkler head in the storage room by the ambulance bay corridor.
2.) The sprinkler head in the Hadley Room #2 education room.

Staff M was present and acknowledged the findings.

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1

Based on observation and interview the facility failed to assure that the corridor is unobstructed. This deficient practice may cause a delay in exiting the building. This will affect 1 out of 16 smoke zones. This facility has a capacity of 222 with a census of 98, 110, 120 and 125 on each day of the survey.

Findings include:

During the tour between 7/18/11 8:00 AM to 7/22/11 5:00 PM the following was observed:

1.) The corridor by the ambulance bay is used for storage of 3 gurneys, crate of X-ray tubes, patient lift, (3) wheeled linen carts, wheeled TV cart, transport chair. This area was approved for gurneys/stretchers only according to Poole Fire Protection letter dated 9/11/08 and approved by KSFMO on 12/31/09. No documentation was available from the local authority having jurisdiction as instructed in the KSFMO letter.

2.) The corridor for education, conference and meeting rooms, has tables and chairs used for registration, and planters.

3.) The direct exit from the chapel has an unsecured plant stand within 10 feet of the exit door.

Staff M was present and acknowledged the findings.

NFPA Standard: No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress from, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1

NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

Based on observation and interview the facility failed to assure that extension cords and power strips were properly used to meet NFPA 70 electrical codes. This deficient practice may cause fire/smoke in 3 out of 16 smoke zones in the building. This facility has a capacity of 222 with a census of 98, 110, 120 and 125 on each day of the survey.

Findings include:

During the tour between 7/18/11 8:00 AM to 7/22/11 5:00 PM the following was found:

1.) The Clean linen storage room has an extension cord for the pencil sharpener.
2.) The laboratory has an extension cord for blood gas machine and has two power strips piggy backed at the desk of Glory Ash.
3.) There are 34 crash carts with electrical medical equipment (EKG, suction and defibrillator) plugged into power strips piggy backed into extension cord reels then to electrical outlets.
4.) The I.C.U. Manager office has an extension cord piggy backed into a power strip for the radio.
5.) The elevator penthouse for #4/5 has an extension cord in use for a fan inside an enclosed space. The fan cord goes through a hole in the sheetrock. It was installed approximately one month ago.

Staff M was present and acknowledged the findings.

NFPA Standard: Temporary electrical power and lighting installations shall be permitted (600 volts or less): (a) During Construction - temporary electric power and lighting installations shall be permitted during the period of construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or similar activities; (b) 90 Days - temporary electrical power and lighting installations shall be permitted for a period not to exceed 90 days for Christmas decorative lighting and similar purposes; (c) Emergencies and Tests - temporary electrical power and lighting installations shall be permitted during emergencies and for tests, experiments, and developmental work.; (d) Removal - temporary wiring shall be removed immediately upon completion of construction or purpose for which the wiring was installed. 1999 NFPA 70, 3-1.2.1

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8

Based on observation and interview the facility failed to assure that fire doors are properly maintained to close and latch. This deficient practice may cause fire/smoke to travel to an adjacent smoke zone in the building. This will affect 2 out of 16 smoke zones in the building. This facility has a capacity of 222 with a census of 98, 110, 120 and 125 on each day of the survey.

Findings include:

During the tour between 7/18/11 8:00 AM to 7/22/11 5:00 PM it was found that the 1.5 hour double fire doors to the ambulance bay did not latch when released from the magnetic hold open devices.

Staff M was present and aware of the finding.

NFPA Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2

Based on observation and interview the facility failed to assure that smoke barrier walls are properly sealed. This deficient practice may cause smoke/fire to travel to adjacent rooms or corridors. This may affect 1 out of 16 smoke zones in the building. This facility has a capacity of 222 with a census of 98, 110, 120 and 125 on each day of the survey.

Findings include:

During the tour between 7/18/11 8:00 AM to 7/22/11 5:00 PM it was found that the Communications closet smoke walls has 3 openings through I.T. 4" conduit that has not been sealed with fire caulk, and a 1" hole through sheetrock that was not filled with a utility conduit or fire caulk.

Staff M2 was present and acknowledged the finding.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

NFPA Standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3

Based on observation and interview the facility failed to assure that the sprinkler system is properly maintained. This deficient practice may cause smoke/fire to travel into the ceiling area. This will affect 1 out of 16 smoke zones in the building. This facility has a capacity of 222 with a census of 98, 110, 120 and 125 on each day of the survey.

Findings include:

During the tour between 7/18/11 8:00 AM to 7/22/11 5:00 PM it was found that the escutcheon was missing from the following:

1.) The sprinkler head in the storage room by the ambulance bay corridor.
2.) The sprinkler head in the Hadley Room #2 education room.

Staff M was present and acknowledged the findings.

NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1

Based on observation and interview the facility failed to assure that the corridor is unobstructed. This deficient practice may cause a delay in exiting the building. This will affect 1 out of 16 smoke zones. This facility has a capacity of 222 with a census of 98, 110, 120 and 125 on each day of the survey.

Findings include:

During the tour between 7/18/11 8:00 AM to 7/22/11 5:00 PM the following was observed:

1.) The corridor by the ambulance bay is used for storage of 3 gurneys, crate of X-ray tubes, patient lift, (3) wheeled linen carts, wheeled TV cart, transport chair. This area was approved for gurneys/stretchers only according to Poole Fire Protection letter dated 9/11/08 and approved by KSFMO on 12/31/09. No documentation was available from the local authority having jurisdiction as instructed in the KSFMO letter.

2.) The corridor for education, conference and meeting rooms, has tables and chairs used for registration, and planters.

3.) The direct exit from the chapel has an unsecured plant stand within 10 feet of the exit door.

Staff M was present and acknowledged the findings.

NFPA Standard: No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress from, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1

NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

Based on observation and interview the facility failed to assure that extension cords and power strips were properly used to meet NFPA 70 electrical codes. This deficient practice may cause fire/smoke in 3 out of 16 smoke zones in the building. This facility has a capacity of 222 with a census of 98, 110, 120 and 125 on each day of the survey.

Findings include:

During the tour between 7/18/11 8:00 AM to 7/22/11 5:00 PM the following was found:

1.) The Clean linen storage room has an extension cord for the pencil sharpener.
2.) The laboratory has an extension cord for blood gas machine and has two power strips piggy backed at the desk of Glory Ash.
3.) There are 34 crash carts with electrical medical equipment (EKG, suction and defibrillator) plugged into power strips piggy backed into extension cord reels then to electrical outlets.
4.) The I.C.U. Manager office has an extension cord piggy backed into a power strip for the radio.
5.) The elevator penthouse for #4/5 has an extension cord in use for a fan inside an enclosed space. The fan cord goes through a hole in the sheetrock. It was installed approximately one month ago.

Staff M was present and acknowledged the findings.

NFPA Standard: Temporary electrical power and lighting installations shall be permitted (600 volts or less): (a) During Construction - temporary electric power and lighting installations shall be permitted during the period of construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or similar activities; (b) 90 Days - temporary electrical power and lighting installations shall be permitted for a period not to exceed 90 days for Christmas decorative lighting and similar purposes; (c) Emergencies and Tests - temporary electrical power and lighting installations shall be permitted during emergencies and for tests, experiments, and developmental work.; (d) Removal - temporary wiring shall be removed immediately upon completion of construction or purpose for which the wiring was installed. 1999 NFPA 70, 3-1.2.1

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8