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Based upon observation and staff interview the facility failed to maintain the construction integrity of smoke compartment barriers on 2 of 5 floors. The findings were:

Observation on 10/4/11 between 11 AM and 3:30 PM revealed the following locations had penetrations in the ceiling:
1. There was a 3 inch square hole in the ceiling of the mail room on the first floor.
2. There was a 3 inch x 18 inch gap in the ceiling tile in the out-patient supply closet.
3. There was an uncovered electrical box in the ceiling of the housekeeping closet on the second floor south.
The plant operations manager confirmed the above findings at the time of the observations.

Reference: NFPA 101, Life Safety Code, 2000 edition.
Section 19.3.6.2.2. Corridor walls and ceilings shall form a barrier to limit the transfer of smoke.

Based upon observation and staff interview the facility failed to ensure one corridor door was resistant to the passage of smoke on 1 of 5 floors. The findings were:

Observation on 10/4/11 at 2:48 PM revealed there were 5 holes in the door between the materials management and medical records rooms. The plant operations manager confirmed the findings at the time of the observation and stated the self-closure device was probably removed and the holes were not filled in.

Reference: NFPA 101, Life Safety Code, 2000 edition.
Section 19.3.6.3.1 Doors protecting corridor openings shall be constructed to resist the passage of smoke.

Based on observation and staff interview, the facility failed to ensure cross corridor smoke barrier doors on 2 of 5 floors were able to resist the passage of smoke. The findings were:

Observation on 10/4/11 between 11 AM and 3:30 PM revealed the following concerns:
1. The cross corridor double doors leading into the inpatient behaviorial unit on the fifth floor north did not seal tightly.
2. The cross corridor doors leading into the ICU also did not seal tightly. At the time of the observation, the plant operations manager stated the door needed a new astragal.
3. The cross corridor double doors leading into the emergency room had six holes in it where it appeared a self closure device had been removed.
The plant operations manager confirmed the above findings at the time of the observations.

Reference: NFPA 101, Life Safety Code, 2000 edition.
Section 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.
Section 8.3.4.1 Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be withour undercuts, louvers, or grilles.

Based upon observation and staff interview, the facility failed to provide proper enclosure of hazardous areas on 3 of 5 floors. The findings were:

Observation on 10/4/11 between 11 AM and 3:30 PM revealed the following concerns:
1. Doors with self-closure devices (SCD) attached but did not latch in their frame were noted on the door to the medical records on the fifth floor outpatient unit south and the housekeeping closet by the ICU cross corridor doors on the fourth floor.
2. Doors with missing SCDs were noted in the housekeeping closet leading into the medical surgery on the fourth floor and in the housekeeping closet on the third floor clinic north.
The plant operations manager confirmed the above findings at the time of the observations.

Ref: NFPA 101, Life Safety Code, 2000 edition, following sections:
18.3.2.1 Hazardous Areas. Any hazardous area shall be protected in accordance with Section 8.4.
8.4.1.2 In new construction, where protection is provided with automatic extinguishing systems without fire-resistive separation, the space protected shall be enclosed with smoke partitions in accordance with 8.2.4.
8.2.4.3.5 Doors shall be self-closing or automatic-closing in accordance with 7.2.1.8.
7.2.1.8.1 Self Closing Devices. A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic closing in accordance with 7.2.1.8.2.

Based upon observation and staff interview the facility failed to maintain 2 of 7 fire alarm components in accordance with the provisions of the Life Safety Code. The findings were:

Observation on 10/4/11 at 1:48 PM revealed the smoke detector in the housekeeping closet on the secord floor south was less that a foot from the ceiling air vent. In addition, the fire alarm indicator appliance, ie horn/strobe, was visually blocked by staff lockers in the locker room opposite the MRI mechanical room. The plant operations manager confirmed the above findings at the time of the observation.

Ref: NFPA 101, Life Safety Code, 2000 edition
Section 19.3.4.5.1 Corridors. An approved automatic smoke detection system shall be installed in all corridors of limited care facilities. Such system shall be in accordance with section 9.6.
Section 9.6 Fire detection, alarm, and communications systems.

Based on observation and staff interview, the facility failed to ensure the spray pattern of two sprinkler heads were not blocked and nine escutcheons on 4 of 5 floors were installed as required. The findings were:

Observation on 10/4/11 between 11 AM and 3:30 PM revealed the following concerns:
1. Ceiling sprinkler heads were obstructed in the following locations: by a conduct in the telephone router room by the IS room and by a ceiling light in the elevator equipment room on the first floor.
2. Single ceiling escutcheons were missing from the following locations: room 578 in the behavioral unit north, in the ICU on the fourth floor by room 11, on the second floor south in the trash shoot room and in the telephone room, in the computer storage room in the ER, in the telephone router room by the IS room, by the elevator equipment room on the first floor, in the nutrition manager's office, and in the environmental services storage room.
3. The plant operations manager confirmed the above findidngs at the time of the observation.

Ref: NFPA 101, Life Safety Code, 2000 edition
Sections 19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7.
9.7.1.1 Each automatic sprinklet system required by another section of this Code shall be in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 1994 Edition.

Based upon observation and staff interview, the facility failed to maintain the installed sprinkler system in accordance with the provisions of NFPA 13 & 25. The findings were:

Observation on 10/4/11at 12:33 PM revealed a large artificial white Christmas tree was sitting in the middle of the floor in the oncology staff room. The top of the tree was less than 6 inches from the ceiling and blocking the spray pattern of the ceiling mounted sprinkler heads.
In addition, observation on 10/4/11at 2:44 PM revealed a cabinet with only 5 extra spare sprinker heads. A sprinkler head wrench handle was also missing. The plant operations manager confirmed the above findings at the time of the observation.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of the Water-Based Fire Protection systems, 1992 edition. Table 2-1
2-4.1.4 A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100 degrees Fahrenheit.

NFPA 13 Standard for the Installation of Sprinkler Systems, 1994 Edition:
13 5-6.5.3 Obstructions that prevents sprinkler discharge from reaching the hazard. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section.

Based upon record review and staff interview, the facility failed to maintain two standard size 10 ABC portable fire extinguishers according NFPA 10. The findings were:

1. Observation on 10/4/11at 1:23 PM revealed a standard size 10 ABC fire extinguisher (less than 40 pounds) attached to the wall in the x-ray hallway. The top of the tank was positioned at 63 inches, greater than the maximal allowed 60 inches. The plant operations manager confirmed the finding at the time of the observation.

2. Observation on 10/4/11at 11:11 AM revealed an unsecured standard size 10 ABC fire extinguisher standing upright on the floor in the housekeeping closet on the fifth floor. The plant operations manager confirmed the above and stated the single extinguisher was a Sampson model and was most likely left over from recent construction.

Ref: NFPA 101, Life Safety Code, 2000 edition
Section 19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10.
NFPA 10, Standard for the Installation of Portable Fire Extinguishers, 1990 edition.
1-6.9 Extinguishers having a gross weight not exceeding 40 lbs shall be installed so that the top of the extinguisher is not more than 5 ft above the floor.
1-6.2 Portable fire extinguishers shall kept in their daily designated place at all times when they are not being used.

Based on observation and staff interview, the facility failed to ensure one of one helium tank was secured. The findings were:

Observation on 10/4/11 at 2:08 PM revealed one large "H" sized helium tank standing in an upright position in the MRI mechanical room. The tank was not secured. Interview with plant operations manager at the time of observation confirmed the tank should be secured.

Reference: NFPA 101, Life Safety Code, 2000 edition.
Section 19.3.2.4 Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.
NFPA 99 Standard for Health Care Facilities, Chapters 4 and 8.
Stand Alone Cylinders and Containers Storage areas: General Considerations. Cylinders must be secured from falling or mechanical shock.

Based on observation and staff interview, the facility failed to ensure compliance with the National Electric Code. The findings were:

1. Observation on 10/4/11 at 12:48 PM revealed an extension cord was being used in the doctor's office of the pathology section. In addition, at 2:01 PM, a medical tech tower was also noted to be plugged into an extension cord in the cardiac rehabilitation gym.
2. Observation on 10/4/11 at 11:22 AM revealed an electric panel was blocked by a housekeeping cart in the MOPR closet in the operating room. A sign on the floor partially covered by the cart read "please do not place items within 3 feet of this panel."
3. Observation on 10/4/11 at 2:21 PM revealed an electrical outlet in the storage room in the C-section suite that was not GFI protected. The outlet was within 6 feet of a sink.
4. The plant operations manager confirmed the above findings at the time of the observations.

Reference: NFPA 101, Life Safety Code, 2000 edition.
Section 19.5.1 Utilities shall comply with the provisions of Section 9.1.
Section 9.1.2 Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code.
Reference: NFPA 70, National Electrical Code, 1999 Edition.
Article 110-26. Spaces about electrical equipment. Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment .
(a) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of (1), (2), and (3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in table 110-26(a).
Table 110-26(a) Nominal Voltage Minimum Clear Distance to Ground (0/150volts) 3 ft.
(b) Clear Space. Working space required by this section shall not be used for storage.
Article 517-20. Wet Locations. (a) All receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection.
Article 400-8. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure.

Based on record review and staff interview, the facility failed to provide a policy for when the sprinkler system was out of service for more than 4 hours in a 24 hour period. The findings were:

Observation on 10/4/11 at 9:48 AM revealed the facility did not have a policy for a sprinkler system outage lasting more than 4 hours. At the time of the review, the plant operations manager acknowledged a policy did not exist for when the sprinkler system was non operational.

Reference: NFPA 101, Life Safety Code, 2000 edition.
Sections 19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7.
9.7.6.1 Where a required automatic sprinkler system is out of service for more that 4 hours in a 24 hour period, the authority having jurisdiction shall be notified and an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

Based upon observation and staff interview the facility failed to maintain the construction integrity of smoke compartment barriers on 2 of 5 floors. The findings were:

Observation on 10/4/11 between 11 AM and 3:30 PM revealed the following locations had penetrations in the ceiling:
1. There was a 3 inch square hole in the ceiling of the mail room on the first floor.
2. There was a 3 inch x 18 inch gap in the ceiling tile in the out-patient supply closet.
3. There was an uncovered electrical box in the ceiling of the housekeeping closet on the second floor south.
The plant operations manager confirmed the above findings at the time of the observations.

Reference: NFPA 101, Life Safety Code, 2000 edition.
Section 19.3.6.2.2. Corridor walls and ceilings shall form a barrier to limit the transfer of smoke.

Based upon observation and staff interview the facility failed to ensure one corridor door was resistant to the passage of smoke on 1 of 5 floors. The findings were:

Observation on 10/4/11 at 2:48 PM revealed there were 5 holes in the door between the materials management and medical records rooms. The plant operations manager confirmed the findings at the time of the observation and stated the self-closure device was probably removed and the holes were not filled in.

Reference: NFPA 101, Life Safety Code, 2000 edition.
Section 19.3.6.3.1 Doors protecting corridor openings shall be constructed to resist the passage of smoke.

Based on observation and staff interview, the facility failed to ensure cross corridor smoke barrier doors on 2 of 5 floors were able to resist the passage of smoke. The findings were:

Observation on 10/4/11 between 11 AM and 3:30 PM revealed the following concerns:
1. The cross corridor double doors leading into the inpatient behaviorial unit on the fifth floor north did not seal tightly.
2. The cross corridor doors leading into the ICU also did not seal tightly. At the time of the observation, the plant operations manager stated the door needed a new astragal.
3. The cross corridor double doors leading into the emergency room had six holes in it where it appeared a self closure device had been removed.
The plant operations manager confirmed the above findings at the time of the observations.

Reference: NFPA 101, Life Safety Code, 2000 edition.
Section 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.
Section 8.3.4.1 Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be withour undercuts, louvers, or grilles.

Based upon observation and staff interview, the facility failed to provide proper enclosure of hazardous areas on 3 of 5 floors. The findings were:

Observation on 10/4/11 between 11 AM and 3:30 PM revealed the following concerns:
1. Doors with self-closure devices (SCD) attached but did not latch in their frame were noted on the door to the medical records on the fifth floor outpatient unit south and the housekeeping closet by the ICU cross corridor doors on the fourth floor.
2. Doors with missing SCDs were noted in the housekeeping closet leading into the medical surgery on the fourth floor and in the housekeeping closet on the third floor clinic north.
The plant operations manager confirmed the above findings at the time of the observations.

Ref: NFPA 101, Life Safety Code, 2000 edition, following sections:
18.3.2.1 Hazardous Areas. Any hazardous area shall be protected in accordance with Section 8.4.
8.4.1.2 In new construction, where protection is provided with automatic extinguishing systems without fire-resistive separation, the space protected shall be enclosed with smoke partitions in accordance with 8.2.4.
8.2.4.3.5 Doors shall be self-closing or automatic-closing in accordance with 7.2.1.8.
7.2.1.8.1 Self Closing Devices. A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic closing in accordance with 7.2.1.8.2.

Based upon observation and staff interview the facility failed to maintain 2 of 7 fire alarm components in accordance with the provisions of the Life Safety Code. The findings were:

Observation on 10/4/11 at 1:48 PM revealed the smoke detector in the housekeeping closet on the secord floor south was less that a foot from the ceiling air vent. In addition, the fire alarm indicator appliance, ie horn/strobe, was visually blocked by staff lockers in the locker room opposite the MRI mechanical room. The plant operations manager confirmed the above findings at the time of the observation.

Ref: NFPA 101, Life Safety Code, 2000 edition
Section 19.3.4.5.1 Corridors. An approved automatic smoke detection system shall be installed in all corridors of limited care facilities. Such system shall be in accordance with section 9.6.
Section 9.6 Fire detection, alarm, and communications systems.

Based on observation and staff interview, the facility failed to ensure the spray pattern of two sprinkler heads were not blocked and nine escutcheons on 4 of 5 floors were installed as required. The findings were:

Observation on 10/4/11 between 11 AM and 3:30 PM revealed the following concerns:
1. Ceiling sprinkler heads were obstructed in the following locations: by a conduct in the telephone router room by the IS room and by a ceiling light in the elevator equipment room on the first floor.
2. Single ceiling escutcheons were missing from the following locations: room 578 in the behavioral unit north, in the ICU on the fourth floor by room 11, on the second floor south in the trash shoot room and in the telephone room, in the computer storage room in the ER, in the telephone router room by the IS room, by the elevator equipment room on the first floor, in the nutrition manager's office, and in the environmental services storage room.
3. The plant operations manager confirmed the above findidngs at the time of the observation.

Ref: NFPA 101, Life Safety Code, 2000 edition
Sections 19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7.
9.7.1.1 Each automatic sprinklet system required by another section of this Code shall be in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 1994 Edition.

Based upon observation and staff interview, the facility failed to maintain the installed sprinkler system in accordance with the provisions of NFPA 13 & 25. The findings were:

Observation on 10/4/11at 12:33 PM revealed a large artificial white Christmas tree was sitting in the middle of the floor in the oncology staff room. The top of the tree was less than 6 inches from the ceiling and blocking the spray pattern of the ceiling mounted sprinkler heads.
In addition, observation on 10/4/11at 2:44 PM revealed a cabinet with only 5 extra spare sprinker heads. A sprinkler head wrench handle was also missing. The plant operations manager confirmed the above findings at the time of the observation.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of the Water-Based Fire Protection systems, 1992 edition. Table 2-1
2-4.1.4 A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100 degrees Fahrenheit.

NFPA 13 Standard for the Installation of Sprinkler Systems, 1994 Edition:
13 5-6.5.3 Obstructions that prevents sprinkler discharge from reaching the hazard. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section.

Based upon record review and staff interview, the facility failed to maintain two standard size 10 ABC portable fire extinguishers according NFPA 10. The findings were:

1. Observation on 10/4/11at 1:23 PM revealed a standard size 10 ABC fire extinguisher (less than 40 pounds) attached to the wall in the x-ray hallway. The top of the tank was positioned at 63 inches, greater than the maximal allowed 60 inches. The plant operations manager confirmed the finding at the time of the observation.

2. Observation on 10/4/11at 11:11 AM revealed an unsecured standard size 10 ABC fire extinguisher standing upright on the floor in the housekeeping closet on the fifth floor. The plant operations manager confirmed the above and stated the single extinguisher was a Sampson model and was most likely left over from recent construction.

Ref: NFPA 101, Life Safety Code, 2000 edition
Section 19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10.
NFPA 10, Standard for the Installation of Portable Fire Extinguishers, 1990 edition.
1-6.9 Extinguishers having a gross weight not exceeding 40 lbs shall be installed so that the top of the extinguisher is not more than 5 ft above the floor.
1-6.2 Portable fire extinguishers shall kept in their daily designated place at all times when they are not being used.

Based on observation and staff interview, the facility failed to ensure one of one helium tank was secured. The findings were:

Observation on 10/4/11 at 2:08 PM revealed one large "H" sized helium tank standing in an upright position in the MRI mechanical room. The tank was not secured. Interview with plant operations manager at the time of observation confirmed the tank should be secured.

Reference: NFPA 101, Life Safety Code, 2000 edition.
Section 19.3.2.4 Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.
NFPA 99 Standard for Health Care Facilities, Chapters 4 and 8.
Stand Alone Cylinders and Containers Storage areas: General Considerations. Cylinders must be secured from falling or mechanical shock.

Based on observation and staff interview, the facility failed to ensure compliance with the National Electric Code. The findings were:

1. Observation on 10/4/11 at 12:48 PM revealed an extension cord was being used in the doctor's office of the pathology section. In addition, at 2:01 PM, a medical tech tower was also noted to be plugged into an extension cord in the cardiac rehabilitation gym.
2. Observation on 10/4/11 at 11:22 AM revealed an electric panel was blocked by a housekeeping cart in the MOPR closet in the operating room. A sign on the floor partially covered by the cart read "please do not place items within 3 feet of this panel."
3. Observation on 10/4/11 at 2:21 PM revealed an electrical outlet in the storage room in the C-section suite that was not GFI protected. The outlet was within 6 feet of a sink.
4. The plant operations manager confirmed the above findings at the time of the observations.

Reference: NFPA 101, Life Safety Code, 2000 edition.
Section 19.5.1 Utilities shall comply with the provisions of Section 9.1.
Section 9.1.2 Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code.
Reference: NFPA 70, National Electrical Code, 1999 Edition.
Article 110-26. Spaces about electrical equipment. Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment .
(a) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of (1), (2), and (3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in table 110-26(a).
Table 110-26(a) Nominal Voltage Minimum Clear Distance to Ground (0/150volts) 3 ft.
(b) Clear Space. Working space required by this section shall not be used for storage.
Article 517-20. Wet Locations. (a) All receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection.
Article 400-8. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure.

Based on record review and staff interview, the facility failed to provide a policy for when the sprinkler system was out of service for more than 4 hours in a 24 hour period. The findings were:

Observation on 10/4/11 at 9:48 AM revealed the facility did not have a policy for a sprinkler system outage lasting more than 4 hours. At the time of the review, the plant operations manager acknowledged a policy did not exist for when the sprinkler system was non operational.

Reference: NFPA 101, Life Safety Code, 2000 edition.
Sections 19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7.
9.7.6.1 Where a required automatic sprinkler system is out of service for more that 4 hours in a 24 hour period, the authority having jurisdiction shall be notified and an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.