HospitalInspections.org

Based on observations made on June 20, 2012, the facility failed to maintain 2-hour fire wall separations between occupancy types.

Findings include:

1. The fire wall which separates the exercise room from the wood shop/maintenance office in the basement of the hospital was observed at 8:00 a.m. on 6/20/12. There were three penetrations for sleeves which were not properly sealed.

2. The fire wall which separates the basement Health Works Fitness Center storeroom from the Hospital elevator control room was observed at 8:10 a.m. on 6/20/12. The fire wall had four penetrations at heat pipes which were not properly sealed.

3. In accordance with 19.3.6.3.4, door-closing devices shall not be required on doors in corridor wall openings other than those serving required exits, smoke barriers, or enclosures of vertical openings and hazardous areas.

The 3-hour door which separates the fitness center from the Hospital basement corridor system was observed at 8:12 a.m. on 6/20/12. The door was blocked open with a 10-pound weight.

4. The fire wall which separates the ambulance garage from the Hospital was observed at 10:45 a.m. on 6/20/12. There were four penetrations in this wall for wire, electrical and sleeves.

Based on observation made on June 19, 2012, the facility failed to maintain a 2 hour fire wall separations between occupancy types.

Findings include:

The network room wall which separates the hospital from the clinic was observed at 3:32 p.m. on 6/19/12. The wall is not 2-hour rated as there is bare wood showing on one portion of the wall.

Based on observation made on June 20, 2012, the facility failed to maintain 2-hour fire wall separations between occupancy types.

Findings include:

1. The fire wall between the hospital basement elevator and the maintenance office was observed at 11:05 a.m. on 6/20/12. There were two penetrations in the fire separation wall, one was for the hydraulic fluid supply shaft and the other was an electrical conduit which was not sealed.

2. The fire wall which separates the new and old basement of the hospital was observed at 11:20 a.m. on 6/20/12. There were two penetrations in the right hand corner for communication wiring.

Based on observations made on June 19, 2012, the facility failed to maintain the fire and smoke resistance rating of wall assemblies in a building of Type II (111) construction.

Findings include:

The electrical room by PAC-U was observed at 4:10 p.m. on 6/19/12. There were three penetrations in the wall to same-day-surgery for electrical conduits.

Based on observations made on June 20, 2012, the facility failed to maintain the fire and smoke resistance rating of wall assemblies in a building of Type II (111) construction.

Findings include:

1. The D-wing nurse call brain room was observed at 8:32 a.m. on 6/20/12. The ceiling tile was out of place at the level where the smoke detection and sprinkler were installed.

2. The D-wing data/phone room was observed at 8:33 a.m. on 6/20/12. There were four penetrations in the ceiling of this room for conduit and communication wire.

3. The network room near the Med Surge patient area was observed at 8:40 a.m. on 6/20/12. The ceiling tile was out at the level where the smoke detection and sprinkler were installed.

4. The human resources data closet was observed at 9:37 a.m. on 6/20/12. The ceiling tile was out at the level where the smoke detection and sprinkler were installed.

5. The radiology department was observed at 10:16 a.m. on 6/20/12. The following deficiencies were noted:
a) in X'-Ray -2, one ceiling tile was out, and
b) in the CT Scan reading/computer room there were ceiling tiles missing.

Based on observations made on June 20, 2012, the facility failed to maintain the fire and smoke resistance rating of wall assemblies in a building of Type II (111) construction.

Findings include:

At the fire wall which separates the new and old portions of the hospital, the wall areas were not fire taped at the double door separation as observed at 11:30 a.m. on 6/20/12.

Based on observations which were made on June 19 and 20, 2012, the facility failed to maintain the fire resistive construction of all corridor walls to be resistant to the passage of smoke.

Findings include:

In accordance with Section 19.3.6.2.1 of NFPA 101, corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.

1. The electrical room by PAC-U was observed at 4:10 p.m. on 6/19/12. There were seven penetrations in the corridor wall for electrical and communication wiring.

2. The data room near same-day-surgery was observed at 4:10 p.m. on 6/19/12. There were 20 penetrations in the corridor walls of this room above the ceiling tile.

3. The D-wing nurse-call brain room was observed at 8:31 a.m. on 6/20/12. There were 10 penetrations in the corridor walls above the ceiling tile.

Based on observations made on June 19 and 20, 2012, the facility failed to assure that the means suitable for keeping corridor doors closed functioned properly.

The findings include:

In accordance with 19.3.6.3.3 of the Life Safety Code hold-open devices that release when the door is pushed or pulled shall be permitted (this does not apply to hazardous area protection). Doors can not be blocked open by furniture, door stops, chocks or devices that necessitate manual releasing action to close the door. Further guidance from Annex A and specifically section A.19.3.6.3.3 states that 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.

The D-wing mens locker room door was exercised at 8:34 a.m. on 6/20/12. The door failed to latch when exercised on three tries.

Based on observations made on June 19, 2012, the facility failed to assure that the means suitable for keeping corridor doors closed functioned properly.

The findings include:


In accordance with Section 18.3.6.3.3, hold-open devices that release when the door is pushed or pulled shall be permitted. Further, Annex A.18.3.6.3.3 goes on to explain that 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.

Finally, Section 18.3.6.3.4 states that door-closing devices shall not be required on doors in corridor wall openings other than those serving required exits, smoke barriers, or enclosures of vertical openings and hazardous areas.

1. The corridor door leading to the restroom in the basement of the hospital was observed at 2:00 p.m. on 6/19/12. The door was blocked open with a wedge.

2. The maintenance wood shop in the basement of the hospital was observed at 2:50 p.m. on 6/19/12. The corridor door to this room was blocked open with a wedge.

Based on observations made on June 19, 2012, the facility failed to assure that the means suitable for keeping corridor doors closed functioned properly.

The findings include:

The corridor door to the loading dock behind the kitchen was exercised at 3:30 p.m. on 6/19/12. The door failed to latch properly when exercised on three different tries.

Based on observation on June 19, 2012, the facility failed to maintain a 2-hour rated ceiling between the Fitness Center and the Hospital located above.

Findings include:

In accordance with NFPA 101 and Section 19.3.1.1, any vertical opening shall be enclosed or protected in accordance with 8.2.5. Further, Section 8.2.5.2 statet that openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

The Fitness Center was observed to ensure that a 2-hour separation was being maintained between facility types. The ceiling of the Fitness Center had three penetrations which appeared to be open to the level above. Some of the penetrations were filled with building foam and it could not be ascertained that they were filled above with an approved material to maintain the proper rating.

Based on observation made on June 20, 2012, the facility did not ensure vertical openings between floors were sealed and/or enclosed by fire resistive construction of at least 1-hour rating.

Findings included:

In accordance with Section 19.3.1.1 of NFPA 101, 2000 Edition, any vertical opening shall be enclosed or protected in accordance with 8.2.5 of the Life Safety Code. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition, 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/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

1. The ceiling space of the B-occupancy Health Works Fitness Center and the level above which included the hospital was observed at 8:15 a.m. on 6/20/12. There were four open penetrations in the concrete floor separation which were not properly sealed.

2. The network work room in the Med-Surge patient care area was observed at 8:35 a.m. on 6/20/12. Three conduits through the floor were not sealed properly between levels.

3. The human resources data closet in the business office was observed at 9:36 a.m. on 6/20/12. One penetration through the floor of this room was not sealed properly between levels.

Based on observations which were made during a tour of the building on June 19 and 20, 2012, it was determined that the facility did not ensure that all doors requiring self closing hardware were properly equipped and/or closed to positive latching.

Findings include:

In accordance with Section 18.2.2.2.6; any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure (except boiler rooms, heater rooms, and mechanical equipment rooms) shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

1. The corridor door at the top of the boiler room stairway was observed at 2:03 p.m. on 6/19/12. The door was not self-closing.

2. The corridor door at the stairway between E-wing and the mechanical room above the kitchen is not self-closing as observed on 6/19/2012 at 2:10 p.m.

Based on observations made on June 20, 2012, the facility failed to install an exit signs for two exits in the Hospital building.

Findings include:

In accordance with Section 19.2.10 of NFPA 101, Life Safety Code; which states: means of egress shall have signs in accordance with Section 7.10.

In accordance with Section 7.10.1.2 (Exits) of NFPA 101, Life Safety Code; which states 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.

1. The exit corridor in the basement of the hospital leading from the exercise room of the B-type occupancy and extending through the basement of the hospital to the stairway was observed at 8:15 a.m. on 6/20/12. There was no exit sign as one stood at the doorway of the Health Works Fitness Center and looked north down the exit corridor of the hospital.

2. The exit corridor behind the emergency department was observed at 7:00 a.m. on 6/20/12. The was no exit sign at the west end of the emergency department.

Based on observations made on June 19 and 20, 2012, the facility failed to maintain the fire resistance rating of smoke barriers.

The findings include:

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition; 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.

1. The smoke barrier walls of the hospital were observed between 1:00 p.m. and 4:30 p.m. on 6/20/12. The smoke barrier wall at home health was observed at 1:35 p.m. There were five sleeves not sealed and another along the north wall not sealed.

2. The smoke barrier wall above the doors leading into the emergency room (ER) were observed at 2:20 p.m. The following deficiencies were noted:
a) a four inch by four inch hole had been cut into the wallboard and not sealed,
b) 1-unsealed phone line,
c) 1-unsealed speaker cable,
d) another round hole, and
e) the HVAC supply was not sealed to the wall correctly as insulation had been used to plug holes around the HVAC supply.

3. The smoke barrier wall next to the outpatient coordinator's office was observed at 3:00 p.m. One small hole had been cut in the smoke wall and not sealed.

4. The smoke barrier wall in C-wing hall by medical records was observed at 3:32 p.m. There were four unsealed penetrations above the double doors in C-hall.

5. The smoke barrier wall in medical records was observed at 3:40 p.m. There were two unsealed penetrations.

6. The smoke barrier wall in the dismissal hall from outpatient surgery was observed at 3:42 p.m. There were 15 unsealed braces through the smoke barrier.

7. The smoke barrier wall in the D-wing at the four corners hall was observed at 4:10 p.m. There was one penetration above the double doors.

Based on observations made on June 19 and 20, 2012, the facility failed to maintain the fire resistance rating of smoke barriers.

The findings include:

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition; 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.

1. The smoke barrier walls of the hospital were observed between 1:00 p.m. and 4:30 p.m. on 6/20/12. The smoke barrier wall at the doors going into surgery were observed at 1:25 p.m. There were three penetrations for communication wiring or electrical conduit.

2. The smoke barrier wall at outpatient surgery was observed at 1:40 p.m. on 6/20/12. The following deficiencies were noted:
a) there were two penetrations directly across from the ice-machine, and
b) there were also four penetrations at the smoke barrier wall near the men's bath and store room.

Based on observations made on June 20, 2012, the facility failed to maintain the fire resistance rating of smoke barriers.

The findings include:

1. In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition; 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.

a) The smoke barrier walls of the hospital were observed between 1:00 p.m. and 4:30 p.m. on 5/20/12. The following areas were discovered with open penetrations in smoke barrier walls. The materials management store room was observed at 1:00 p.m., there were 6 penetrations in the smoke barrier wall.

b) The office area of materials management was observed at 1:07 p.m. There were two penetrations for communication cable in the smoke barrier walls.

c) The materials management storeroom was observed at 1:50 p.m. There were three electrical conduits which were not sealed properly.

d) The X-Ray hall near the second set of double doors was observed at 1:55 p.m. There were two penetrations above the double doors at the smoke barrier wall.

e) The X-Ray hall above the doors into surgery were observed at 2:00 p.m. One penetration was found unsealed for communication wiring.

f) The smoke barrier wall in the pharmacy was observed at 3:10 p.m. Four penetrations were found in the wall which were unsealed.

g) The smoke barrier wall in the gift shop was observed at 3:15 p.m. Two penetrations were found in the wall which were unsealed for communication wiring.

Based on observations made on June 20, 2012, the facility failed to assure that smoke barrier doors closed tightly to prevent the passage of smoke.

The findings include:

In accordance with 18.3.7.6, doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6. Further, Section 18.2.2.2.6 states that any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure (except boiler rooms, heater rooms, and mechanical equipment rooms) shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility. Finally, Annex A.18.2.2.2.6 states that it is desirable to keep doors in exit passageways, stair enclosures, horizontal exits, smoke barriers, and required enclosures around hazardous areas closed at all times to impede the travel of smoke and fire gases. Functionally, however, this involves decreased efficiency and limits patient observation by the staff of an institution. To accommodate such needs, it is practical to presume that such doors will be kept open, even to the extent of employing wood chocks and other makeshift devices. Doors in exit passageways, horizontal exits, and smoke barriers should, therefore, be equipped with automatic hold-open devices activated by the methods described, regardless of whether the original installation of the doors was predicated on a policy of keeping them closed.

The gift shop was observed at 3:12 p.m. on 6/20/12. The corridor door was observed to be part of a smoke barrier. The door was blocked open with a chock.

Based on observations made on June 20, 2012, the facility failed to assure that smoke barrier doors closed tightly to prevent the passage of smoke.

The findings include:

In accordance with Section 18.2.2.2.6; any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure (except boiler rooms, heater rooms, and mechanical equipment rooms) shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility. Finally, Annex A.18.2.2.2.6 states that it is desirable to keep doors in exit passageways, stair enclosures, horizontal exits, smoke barriers, and required enclosures around hazardous areas closed at all times to impede the travel of smoke and fire gases. Functionally, however, this involves decreased efficiency and limits patient observation by the staff of an institution. To accommodate such needs, it is practical to presume that such doors will be kept open, even to the extent of employing wood chocks and other makeshift devices. Doors in exit passageways, horizontal exits, and smoke barriers should, therefore, be equipped with automatic hold-open devices activated by the methods described, regardless of whether the original installation of the doors was predicated on a policy of keeping them closed.

The smoke barrier door at radiology was observed at 2:11 p.m. on 6/20/12. The door was being held open with a chock.

Based on observation on June 19, and 20, 2012, the facility failed to provide doors on hazardous areas which closed to a smoke tight surface and doors for hazardous areas which met the intent of the Code.

Findings include:

1. The elevator maintenance room in the hospital was observed at 1:10 p.m. on 6/19/12. The hydraulic fluid line extended through the east wall and was not properly sealed.

Section 8.4.1.3 states that doors in barriers required to have a fire resistance rating shall have a 3/4 hour fire protection rating and shall be self-closing in accordance with 7.2.1.8.

2. The medical records storeroom in the basement was observed at 1:30 p.m. on 6/19/12. A large access hole (30 inches by 30 inches) was left unsealed between the storeroom and the crawl space beneath the hospital which is unsprinkled. There was no rated door covering this access space.

Based on observation on June 19, and 20, 2012, the facility failed to provide doors on hazardous areas which closed to a smoke tight surface, maintain the rating of 1 hour walls, and maintain doors for hazardous areas.

Findings include:

In accordance with NFPA 101 and section 19.3.2.1 Hazardous Areas, any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have non-rated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Section 8.4.1.3 of NFPA 101, Life Safety Code states that doors in barriers required to have a fire resistance rating shall have a 3/4 hour fire protection rating and shall be self-closing in accordance with 7.2.1.8.

1. The old basement storeroom was observed at 1:50 p.m. on 6/19/12. The following deficiencies were noted:
a) Twenty penetrations were either unsealed or sealed with building foam, which does not meet the requirements for a 1-hour rated wall.
b) The large heating ventilation and air-conditioning (HVAC) supply and return air were not properly sealed where they enter the crawl space.
c) The fire rated doors into the crawl spaces were not latched as an extension cord was run through the doors.

2. The compressor room was observed at 2:00 p.m. on 6/19/12. There were two penetrations above the door from the boiler room which were not sealed.

3. The wall between the compressor room and the boiler room was observed at 2:00 p.m. on 6/19/12. There were four penetrations in the wall which were unsealed.

4. The boiler room of the hospital was observed at 2:00 p.m. on 6/19/12. The following deficiencies were noted:
a) There were five open penetrations between the boiler room which was separated with 2-hour barrier and the adjoining storeroom which was a 1-hour rating.
b) There were also five penetrations between the boiler room and the air-conditioner room, which was also one-hour rated.

5. The air-conditioner room near the boiler room was observed at 2:10 p.m. on 6/19/12. There were six penetrations of the corridor wall which were not sealed.

6. The storeroom housing the medical air equipment was observed at 7:50 a.m. on 6/20/12. There was one penetration in the north wall for electrical wiring.

7. The generator room was observed at 7:51 a.m. on 6/20/12. There was one penetration in the north wall of this room for a sprinkler pipe.

Based on observation on June 20, 2012, the facility failed to provide doors on hazardous areas which were self closing.

Findings include:

In accordance with Section 18.3.2.1; any hazardous area shall be protected in accordance with Section 8.4. Section 8.4.1.3 of NFPA 101, Life Safety Code states that doors in barriers required to have a fire resistance rating shall have a 3/4 hour fire protection rating and shall be self-closing in accordance with 7.2.1.8.

The materials management area and office space was observed at 8:28 a.m. on 6/20/12. The door between the office and the storeroom was not self-closing.

Based on observations made on June 19, 2012 the facility failed to maintain the existing width of an exit corridor.

Findings include:

In accordance with 4.6.7 of the Life Safety Code corridors that were originally designed and code approved to be 8 feet in width cannot be reduced in width.

The exit corridor system for the basement of the Hospital was observed at 2:00 p.m. on 6/19/12. There was an abundance of stored items in the exit corridors in the basement including files, chairs, desks, furniture, etc. The Health Works Fitness Center was used by high school training classes and this amount of stored items in the corridor system could affect exiting in cases of emergency.

Based on observation on June 19, 2012, the facility failed to maintain battery pack emergency lighting in Suite 110.

Findings include:
In accordance with 39.2.8 Illumination of Means of Egress.
Means of egress shall be illuminated in accordance with Section 7.8.

Clinic suite 110 was observed at 10:00 a.m. on 6/19/2012. The battery pack style emergency light fixture was tested and the fixture failed to illuminate.

Based on observation made on June 19, 2012, the facility failed to ensure that the breaker which controlled the fire alarm control panel was permanently marked in red.

Findings include:

In accordance with Section 1-5.2.5.2 of NFPA 72, (1999 edition); the connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

The FACP and connecting services were reviewed at 10:00 a.m. on 6/20/2012. The Simplex 4100 FACP located on the wall directly across from the hospital nurse's station was identified as to what dedicated power circuit branch provided power for it with the breaker and panel numbers; however, when viewing the electric panel which served the FACP, the breaker was not identified in RED.

Based on observation on June 19, 2012, the facility did not ensure complete coverage of the building by an approved automatic sprinkler system.

Findings include:

The outpatient surgery area of the hospital was observed at 4:20 p.m. on 6/19/12. A three foot by four foot area near the ice machine has short walls which extend out from walls which block off the installed sprinkler pattern. There is no sprinkler head which covers an alcove small area near the ice-machine.

Based on observation, the facility did not ensure complete coverage of the building by an approved automatic sprinkler system.

Findings include:

The stairway from the boiler room to D-wing was observed at 2:01 p.m. on 6/19/12. The stairway used to go to the outside of the building, but has now been enclosed and is not sprinkled by the present sprinkler system.

Based on record review and observations that were made on June 19 and 20, 2012, the facility failed to maintain the sprinkler system in accordance with NFPA 25, 1998 Edition.

The findings include:

All control valves shall be inspected to verify that the valves are in the following condition per section 9-3.3.2 of NFPA 25:
(a) In the normal open or closed position
(b) Properly sealed, locked, or supervised
(c) Accessible
(d) Provided with appropriate wrenches
(e) Free from external leaks
(f) Provided with appropriate identification

1. The valves which control the anti-freeze loops on the sprinkler risers were observed to be not supervised as the locks were not locked at observed at 9:25 a.m. on 6/19/12.

2. The sprinkler quarterly reports were reviewed at 9:30 a.m. on 6/19/12. They also indicated that the antifreeze valves were not supervised by lock or interconnected to the fire alarm.

Based on observation, the facility failed to maintain the sprinkler system and its components in accordance with the standards of NFPA 13, 1999 Edition.

The findings include:

In accordance with NFPA 13 and Section 3-2.7.2; escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. Further guidance in Annex A-3-2.7.2 states that the use of the wrong type of escutcheon with recessed or flush-type sprinklers can result in severe disruption of the spray pattern, which can destroy the effectiveness of the sprinkler.

1. Suite 111 of the Clinic was observed at 10:10 a.m. on 6/19/2012. An escutcheon ring was missing on the ceiling of this suite.

2. Suite 108 in the Clinic was observed at 10:12 a.m. on 6/19/2012. An escutcheon ring was missing in the bathroom of this suite.

3. The north end corridor space of the Clinic was observed at 11:45 a.m. on 6/19/2012. An escutcheon ring was missing in the corridor next to the double doors to the hospital.

Based on review of the sprinkler service and inspection reports on June 19 and 20, 2012, the facility failed to assure that the backflow preventer device(s) for the sprinkler system had been tested on an annual basis in accordance with NFPA 25, 1998 Edition.

The findings include:

All backflow preventers installed in fire protection system piping shall be tested annually per section 9-6.2.1 of NFPA 25 in accordance with the following:
(a) A forward flow test shall be conducted at the system demand, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer.
(b) A backflow performance test, as required by the authority having jurisdiction, shall be conducted at the completion of the forward flow test.
Exception No. 1: For backflow preventers sized 2 in. (50.8 mm) and under, it shall be acceptable to conduct the forward flow test without measuring flow, where the test outlet is of a size to flow the system demand.
Exception No. 2: Where water rationing shall be enforced during shortages lasting more than 1 year, an internal inspection of the backflow preventer to ensure the check valves will fully open shall be acceptable in lieu of conducting the annual forward flow test.
Exception No. 3: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be completed at the maximum flow rate possible.
Exception No. 4: The forward flow test shall not be required where annual fire pump testing causes the system demand to flow through the backflow preventer device.

The sprinkler service and inspection reports were reviewed at 1:10 p.m. on 6/19/2012 at the facility. The reports examined did not contain verification that the backflow preventer device(s) had been tested on an annual basis as required by NFPA 25.

Based on review of the sprinkler service and inspection reports on June 19 and 20, 2012, the facility failed to maintain the sprinkler system and all its components in accordance with the standards of NFPA 25, 1998 Edition and NFPA 13, 1999 Edition.

Findings include:

In accordance with NFPA 25 and Section 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.

1. The sprinkler heads throughout the kitchen (more than 10) were full of lint as observed at 3:25 p.m. on 6/19/12.

In accordance with NFPA 13 and Section 3-2.7.2; escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. Further the in Annex A-3-2.7.2 the guidance is that the use of the wrong type of escutcheon with recessed or flush-type sprinklers can result in severe disruption of the spray pattern, which can destroy the effectiveness of the sprinkler.

2. An escutcheon ring was missing in the corridor near the network storeroom as observed at 3:33 p.m. on 6/19/12.

Based on surveyor observations made on June 19 and 20, 2012, the facility failed to maintain the sprinkler system and all its components in accordance with the standards of NFPA 13, 1999 Edition.

Findings include:

In accordance with NFPA 13 and Section 3-2.7.2; escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. Further the in Annex A-3-2.7.2 the guidance is that the use of the wrong type of escutcheon with recessed or flush-type sprinklers can result in severe disruption of the spray pattern, which can destroy the effectiveness of the sprinkler.

1. There was an escutcheon ring missing on the dirty side of CSR as observed at 4:00 p.m. on 6/19/12.

2. An escutcheon ring was missing on the ceiling of the materials management office as observed at 8:30 a.m. on 6/20/12.

Based on surveyor observations made on June 19, 2012, the facility failed to maintain the sprinkler system and all its components in accordance with the standards of NFPA 25, 1998 Edition.

Findings include:

In accordance with NFPA 13 and Section 3-2.7.2; escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. Further the in Annex A-3-2.7.2 the guidance is that the use of the wrong type of escutcheon with recessed or flush-type sprinklers can result in severe disruption of the spray pattern, which can destroy the effectiveness of the sprinkler.

1. There was an escutcheon ring missing on the ceiling of the woodshop as observed at 1:20 p.m. on 6/19/12.

2. There was an escutcheon ring missing on the ceiling of the exit corridor near the kitchen exit as observed at 2:35 p.m. on 6/19/12.

Based on observations made on June 19, 2012, the facility did not ensure portable fire extinguishers were mounted in accordance with the standards of NFPA 10.

Findings include:

In accordance with NFPA 10, 1998 Edition, and section 4-3.2; periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility

Additionally, in accordance with 1-6.7 and 1-6.10 of NFPA 10, (1998 edition); portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet (60 Inches) above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet (42 inches) above the floor.

The pathology department was observed at 4:15 p.m. on 6/19/12. The portable fire extinguisher was sitting in a corner atop a counter and not installed/mounted on a wall accessible to anyone who could possibly use it. The top of the extinguisher was at 68 inches above the floor.

Based on observation and staff interview on June 19, 2012, the facility did not ensure that oxygen cylinders were supported from falling over while in storage.

Findings include:

In accordance with sections 8-3.1.11.2(h) and 4-3.5.2.1 (b27) of NFPA 99 (1999 edition), freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

The maintenance shop in the basement of the hospital was observed at 1:00 p.m. on 6/19/12. There were two oxygen cylinders sitting near the back wall of the shop which had not been properly secured.

Based on observation on June 20, 2012, the facility did not ensure that oxygen cylinders were supported from falling over while in storage.

Findings include:

In accordance with sections 8-3.1.11.2(h) and 4-3.5.2.1 (b27) of NFPA 99 (1999 Edition), freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

The main oxygen store room for the hospital was observed at 8:10 a.m. on 6/20/12. There were four oxygen cylinders which had not been properly secured behind chains.

Based on observation and record review on June 19 and 20, 2012, the facility failed to to maintain the reserve oxygen supply, provide the oxygen system with duplex final line pressure regulator and ensure area alarms functioned properly. These deficiencies were per the March 28, 2012 Piped Medical Gas System Evaluation by an outside contractor.

Findings include:

1. In accordance with NFPA 99, 1999 Edition and Section 4-3.1.1.6(b); the reserve supply shall consist of three or more manifolded high-pressure cylinders connected as required under 4-3.1.1.8(b), and either shall be equipped with check valves as required in 4-3.1.1.5(b) or shall be provided with an actuating switch that shall operate the master signals when the reserve supply drops to one day ' s supply.

The reserve bank for the oxygen supply tank was reading 200 psig which is virtually empty per the March 28, 2012 Piped Medical Gas System Evaluation by an outside contractor.

2. In accordance with Section 4-3.1.1.8 (1) (g) of NFPA 99 (1999 Edition); final line regulators shall be duplexed with suitable valving to permit service to the regulators without completely shutting down the gas piping system.

The bulk oxygen systems were observed and reviewed at 8:10 a.m. on 6/20/12. The Oxygen system have only one final line regulator. By Code, they are to be duplexed with suitable valving to permit service on the regulators without completely shutting down the gas piping system.

3. In accordance wih NFPA 99 and Section 4-3.1.2.2 (b.), cancelable audible indication of an alarm condition. The audible indicator shall produce a minimum of 80 dBA measured at 3 ft (1 m). A second indicated condition occurring while the alarm is silenced shall reinitiate the audible signal. Further Section 4-3.1.2.2(e), indicated that the scale range of positive pressure analog gauges shall be such that the normal reading falls within the middle 50 percent of the scale. The scale range of digital gauges shall be not more than two times the working pressure. The rated accuracy of pressure gauges used for testing shall be one percent (full scale) or better at the point of reading. Pressure gauges shall be in compliance with ANSI/ASME B-40.1, Gauges, Pressure Indicating Dial-Type, Elastic Elements.

The following deficiencies were noted by per the March 28, 2012 Piped Medical Gas System Evaluation by an outside contractor:
a) the area alarm outside room 305 in OB had an oxygen signal which failed to silence when tested, and
b) there was a problem with the area alarm panel in OR-2 as the panel only indicated pressure up to 122 psig.

Based on observation and record review June 19, 2012, all of the anesthetizing locations were not protected in accordance with NFPA 99, Standard for Health Care Facilities per the March 28, 2012 Piped Medical Gas System Evaluation by an outside contractor.


In accordance with Section 4-3.1.2.3 (n) of NFPA 99 (1999 Edition); a shutoff valve shall be located outside each anesthetizing location in each medical gas line, so located as to be readily accessible at all times for use in an emergency. These valves shall be so arranged that shutting off the supply of gas to any one operating room or anesthetizing location will not affect the others. Valves shall be of an approved type, mounted on a pedestal or otherwise properly safeguarded against physical damage, and marked in accordance with 4-3.5.4.2.

Finding include:

The annual report for the Piped Medical Gas System Evaluation was reviewed at 10:30 a.m. on 6/19/12. The report indicated that the zone valves in rooms 305 and 306 of OB are controlled by inline valves and would affect other areas when turned off. Further, the report indicated that conditions exist where a potential problem could arise if action is not taken in the future.

Based on observation on June 19, 2012, the facility failed to meet the standards of either NFPA 70 in regards to electrical service in the building.

Findings include:

In accordance with Section 39.5.1 Utilities; utilities shall comply with the provisions of Section 9.1. Section 9.1.2 states that electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

In accordance with Article 110-27(b); in locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage.

1. Exam rooms 2 and 3 in Suite 108 were observed at 10:20 a.m. on 6/19/2012. There were heating pads plugged into wall outlets which were then inserted into drawers which were closed on the cords.

In accordance with Article 370-25, in completed installations, each box shall have a cover, faceplate, or fixture canopy.

2. The cleaning room in Suite 101 was observed at 10:45 a.m. on 6/19/2012. An electrical outlet cover was missing in this room.

Based on observations made on June 19 and 20, 2012, the facility failed to maintain the electrical system in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS).

The findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions per Article 240-4(b)(3) of NFPA 70 or by interpretations issued by the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings.

1. The old basement storeroom was observed at 2:00 p.m. on 6/19/12. An extension cord was in-use to power a paging system. (Note: the cord was removed at the time of the survey process.)

2. The pharmacy was observed at 3:05 p.m. on 6/19/12. Two surge cords were found connected in series for the OPHUS cart system.

3. The case management office was observed at 8:35 a.m. on 6/20/12. There were 2 extension cords in-use under desks. (Note: the cords were removed at the time of the survey process).

4. The network room in the medical surgical patient area was observed at 8:40 a.m. on 6/20/12. An electrical cover was missing in this room.

5. The sleep study office was observed at 9:00 a.m. on 6/20/12. There were 2-surge cords found in series.

6. The information technology (IT) office was observed at 9:20 a.m. on 6/20/12. An extension cord was found in-use in this room.

7. The business office areas were observed at 9:25 a.m. on 6/20/12. There were 2 multi-plug adaptors in use in this area.

8. The X-Ray work area was observed at 10:15 a.m. on 6/20/12. There were 2 surge cords not mounted to the wall, but dangled by the cord. Also, there were 2 surge cords plugged in series in this work area.

9. The respiratory therapy office area was observed at 10:35 a.m. on 6/20/12. There were 2 surge cords not mounted to the wall. Also, a microwave oven was plugged into a surge cord.

10. The radiology work areas were observed at 2:10 p.m. on 6/20/12. One surge cord extended through a doorway of a smoke barrier, and the door in the barrier would not close.

Based on observations made on June 20, 2012, the facility failed to maintain the electrical system in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS).

The findings include:

The intensive care unit was observed at 8:36 a.m. on 6/20/12. One surge cord was found not laying flat on the floor or mounted to the wall, but was dangling by the cord.

Based on observations made on June 20, 2012, the facility failed to maintain 2-hour fire wall separations between occupancy types.

Findings include:

1. The fire wall which separates the exercise room from the wood shop/maintenance office in the basement of the hospital was observed at 8:00 a.m. on 6/20/12. There were three penetrations for sleeves which were not properly sealed.

2. The fire wall which separates the basement Health Works Fitness Center storeroom from the Hospital elevator control room was observed at 8:10 a.m. on 6/20/12. The fire wall had four penetrations at heat pipes which were not properly sealed.

3. In accordance with 19.3.6.3.4, door-closing devices shall not be required on doors in corridor wall openings other than those serving required exits, smoke barriers, or enclosures of vertical openings and hazardous areas.

The 3-hour door which separates the fitness center from the Hospital basement corridor system was observed at 8:12 a.m. on 6/20/12. The door was blocked open with a 10-pound weight.

4. The fire wall which separates the ambulance garage from the Hospital was observed at 10:45 a.m. on 6/20/12. There were four penetrations in this wall for wire, electrical and sleeves.

Based on observation made on June 19, 2012, the facility failed to maintain a 2 hour fire wall separations between occupancy types.

Findings include:

The network room wall which separates the hospital from the clinic was observed at 3:32 p.m. on 6/19/12. The wall is not 2-hour rated as there is bare wood showing on one portion of the wall.

Based on observation made on June 20, 2012, the facility failed to maintain 2-hour fire wall separations between occupancy types.

Findings include:

1. The fire wall between the hospital basement elevator and the maintenance office was observed at 11:05 a.m. on 6/20/12. There were two penetrations in the fire separation wall, one was for the hydraulic fluid supply shaft and the other was an electrical conduit which was not sealed.

2. The fire wall which separates the new and old basement of the hospital was observed at 11:20 a.m. on 6/20/12. There were two penetrations in the right hand corner for communication wiring.

Based on observations made on June 19, 2012, the facility failed to maintain the fire and smoke resistance rating of wall assemblies in a building of Type II (111) construction.

Findings include:

The electrical room by PAC-U was observed at 4:10 p.m. on 6/19/12. There were three penetrations in the wall to same-day-surgery for electrical conduits.

Based on observations made on June 20, 2012, the facility failed to maintain the fire and smoke resistance rating of wall assemblies in a building of Type II (111) construction.

Findings include:

1. The D-wing nurse call brain room was observed at 8:32 a.m. on 6/20/12. The ceiling tile was out of place at the level where the smoke detection and sprinkler were installed.

2. The D-wing data/phone room was observed at 8:33 a.m. on 6/20/12. There were four penetrations in the ceiling of this room for conduit and communication wire.

3. The network room near the Med Surge patient area was observed at 8:40 a.m. on 6/20/12. The ceiling tile was out at the level where the smoke detection and sprinkler were installed.

4. The human resources data closet was observed at 9:37 a.m. on 6/20/12. The ceiling tile was out at the level where the smoke detection and sprinkler were installed.

5. The radiology department was observed at 10:16 a.m. on 6/20/12. The following deficiencies were noted:
a) in X'-Ray -2, one ceiling tile was out, and
b) in the CT Scan reading/computer room there were ceiling tiles missing.

Based on observations made on June 20, 2012, the facility failed to maintain the fire and smoke resistance rating of wall assemblies in a building of Type II (111) construction.

Findings include:

At the fire wall which separates the new and old portions of the hospital, the wall areas were not fire taped at the double door separation as observed at 11:30 a.m. on 6/20/12.

Based on observations which were made on June 19 and 20, 2012, the facility failed to maintain the fire resistive construction of all corridor walls to be resistant to the passage of smoke.

Findings include:

In accordance with Section 19.3.6.2.1 of NFPA 101, corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.

1. The electrical room by PAC-U was observed at 4:10 p.m. on 6/19/12. There were seven penetrations in the corridor wall for electrical and communication wiring.

2. The data room near same-day-surgery was observed at 4:10 p.m. on 6/19/12. There were 20 penetrations in the corridor walls of this room above the ceiling tile.

3. The D-wing nurse-call brain room was observed at 8:31 a.m. on 6/20/12. There were 10 penetrations in the corridor walls above the ceiling tile.

Based on observations made on June 19 and 20, 2012, the facility failed to assure that the means suitable for keeping corridor doors closed functioned properly.

The findings include:

In accordance with 19.3.6.3.3 of the Life Safety Code hold-open devices that release when the door is pushed or pulled shall be permitted (this does not apply to hazardous area protection). Doors can not be blocked open by furniture, door stops, chocks or devices that necessitate manual releasing action to close the door. Further guidance from Annex A and specifically section A.19.3.6.3.3 states that 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.

The D-wing mens locker room door was exercised at 8:34 a.m. on 6/20/12. The door failed to latch when exercised on three tries.

Based on observations made on June 19, 2012, the facility failed to assure that the means suitable for keeping corridor doors closed functioned properly.

The findings include:


In accordance with Section 18.3.6.3.3, hold-open devices that release when the door is pushed or pulled shall be permitted. Further, Annex A.18.3.6.3.3 goes on to explain that 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.

Finally, Section 18.3.6.3.4 states that door-closing devices shall not be required on doors in corridor wall openings other than those serving required exits, smoke barriers, or enclosures of vertical openings and hazardous areas.

1. The corridor door leading to the restroom in the basement of the hospital was observed at 2:00 p.m. on 6/19/12. The door was blocked open with a wedge.

2. The maintenance wood shop in the basement of the hospital was observed at 2:50 p.m. on 6/19/12. The corridor door to this room was blocked open with a wedge.

Based on observations made on June 19, 2012, the facility failed to assure that the means suitable for keeping corridor doors closed functioned properly.

The findings include:

The corridor door to the loading dock behind the kitchen was exercised at 3:30 p.m. on 6/19/12. The door failed to latch properly when exercised on three different tries.

Based on observation on June 19, 2012, the facility failed to maintain a 2-hour rated ceiling between the Fitness Center and the Hospital located above.

Findings include:

In accordance with NFPA 101 and Section 19.3.1.1, any vertical opening shall be enclosed or protected in accordance with 8.2.5. Further, Section 8.2.5.2 statet that openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

The Fitness Center was observed to ensure that a 2-hour separation was being maintained between facility types. The ceiling of the Fitness Center had three penetrations which appeared to be open to the level above. Some of the penetrations were filled with building foam and it could not be ascertained that they were filled above with an approved material to maintain the proper rating.

Based on observation made on June 20, 2012, the facility did not ensure vertical openings between floors were sealed and/or enclosed by fire resistive construction of at least 1-hour rating.

Findings included:

In accordance with Section 19.3.1.1 of NFPA 101, 2000 Edition, any vertical opening shall be enclosed or protected in accordance with 8.2.5 of the Life Safety Code. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition, 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/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

1. The ceiling space of the B-occupancy Health Works Fitness Center and the level above which included the hospital was observed at 8:15 a.m. on 6/20/12. There were four open penetrations in the concrete floor separation which were not properly sealed.

2. The network work room in the Med-Surge patient care area was observed at 8:35 a.m. on 6/20/12. Three conduits through the floor were not sealed properly between levels.

3. The human resources data closet in the business office was observed at 9:36 a.m. on 6/20/12. One penetration through the floor of this room was not sealed properly between levels.

Based on observations which were made during a tour of the building on June 19 and 20, 2012, it was determined that the facility did not ensure that all doors requiring self closing hardware were properly equipped and/or closed to positive latching.

Findings include:

In accordance with Section 18.2.2.2.6; any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure (except boiler rooms, heater rooms, and mechanical equipment rooms) shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

1. The corridor door at the top of the boiler room stairway was observed at 2:03 p.m. on 6/19/12. The door was not self-closing.

2. The corridor door at the stairway between E-wing and the mechanical room above the kitchen is not self-closing as observed on 6/19/2012 at 2:10 p.m.

Based on observations made on June 20, 2012, the facility failed to install an exit signs for two exits in the Hospital building.

Findings include:

In accordance with Section 19.2.10 of NFPA 101, Life Safety Code; which states: means of egress shall have signs in accordance with Section 7.10.

In accordance with Section 7.10.1.2 (Exits) of NFPA 101, Life Safety Code; which states 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.

1. The exit corridor in the basement of the hospital leading from the exercise room of the B-type occupancy and extending through the basement of the hospital to the stairway was observed at 8:15 a.m. on 6/20/12. There was no exit sign as one stood at the doorway of the Health Works Fitness Center and looked north down the exit corridor of the hospital.

2. The exit corridor behind the emergency department was observed at 7:00 a.m. on 6/20/12. The was no exit sign at the west end of the emergency department.

Based on observations made on June 19 and 20, 2012, the facility failed to maintain the fire resistance rating of smoke barriers.

The findings include:

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition; 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.

1. The smoke barrier walls of the hospital were observed between 1:00 p.m. and 4:30 p.m. on 6/20/12. The smoke barrier wall at home health was observed at 1:35 p.m. There were five sleeves not sealed and another along the north wall not sealed.

2. The smoke barrier wall above the doors leading into the emergency room (ER) were observed at 2:20 p.m. The following deficiencies were noted:
a) a four inch by four inch hole had been cut into the wallboard and not sealed,
b) 1-unsealed phone line,
c) 1-unsealed speaker cable,
d) another round hole, and
e) the HVAC supply was not sealed to the wall correctly as insulation had been used to plug holes around the HVAC supply.

3. The smoke barrier wall next to the outpatient coordinator's office was observed at 3:00 p.m. One small hole had been cut in the smoke wall and not sealed.

4. The smoke barrier wall in C-wing hall by medical records was observed at 3:32 p.m. There were four unsealed penetrations above the double doors in C-hall.

5. The smoke barrier wall in medical records was observed at 3:40 p.m. There were two unsealed penetrations.

6. The smoke barrier wall in the dismissal hall from outpatient surgery was observed at 3:42 p.m. There were 15 unsealed braces through the smoke barrier.

7. The smoke barrier wall in the D-wing at the four corners hall was observed at 4:10 p.m. There was one penetration above the double doors.

Based on observations made on June 19 and 20, 2012, the facility failed to maintain the fire resistance rating of smoke barriers.

The findings include:

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition; 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.

1. The smoke barrier walls of the hospital were observed between 1:00 p.m. and 4:30 p.m. on 6/20/12. The smoke barrier wall at the doors going into surgery were observed at 1:25 p.m. There were three penetrations for communication wiring or electrical conduit.

2. The smoke barrier wall at outpatient surgery was observed at 1:40 p.m. on 6/20/12. The following deficiencies were noted:
a) there were two penetrations directly across from the ice-machine, and
b) there were also four penetrations at the smoke barrier wall near the men's bath and store room.

Based on observations made on June 20, 2012, the facility failed to maintain the fire resistance rating of smoke barriers.

The findings include:

1. In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition; 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.

a) The smoke barrier walls of the hospital were observed between 1:00 p.m. and 4:30 p.m. on 5/20/12. The following areas were discovered with open penetrations in smoke barrier walls. The materials management store room was observed at 1:00 p.m., there were 6 penetrations in the smoke barrier wall.

b) The office area of materials management was observed at 1:07 p.m. There were two penetrations for communication cable in the smoke barrier walls.

c) The materials management storeroom was observed at 1:50 p.m. There were three electrical conduits which were not sealed properly.

d) The X-Ray hall near the second set of double doors was observed at 1:55 p.m. There were two penetrations above the double doors at the smoke barrier wall.

e) The X-Ray hall above the doors into surgery were observed at 2:00 p.m. One penetration was found unsealed for communication wiring.

f) The smoke barrier wall in the pharmacy was observed at 3:10 p.m. Four penetrations were found in the wall which were unsealed.

g) The smoke barrier wall in the gift shop was observed at 3:15 p.m. Two penetrations were found in the wall which were unsealed for communication wiring.

Based on observations made on June 20, 2012, the facility failed to assure that smoke barrier doors closed tightly to prevent the passage of smoke.

The findings include:

In accordance with 18.3.7.6, doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6. Further, Section 18.2.2.2.6 states that any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure (except boiler rooms, heater rooms, and mechanical equipment rooms) shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility. Finally, Annex A.18.2.2.2.6 states that it is desirable to keep doors in exit passageways, stair enclosures, horizontal exits, smoke barriers, and required enclosures around hazardous areas closed at all times to impede the travel of smoke and fire gases. Functionally, however, this involves decreased efficiency and limits patient observation by the staff of an institution. To accommodate such needs, it is practical to presume that such doors will be kept open, even to the extent of employing wood chocks and other makeshift devices. Doors in exit passageways, horizontal exits, and smoke barriers should, therefore, be equipped with automatic hold-open devices activated by the methods described, regardless of whether the original installation of the doors was predicated on a policy of keeping them closed.

The gift shop was observed at 3:12 p.m. on 6/20/12. The corridor door was observed to be part of a smoke barrier. The door was blocked open with a chock.

Based on observations made on June 20, 2012, the facility failed to assure that smoke barrier doors closed tightly to prevent the passage of smoke.

The findings include:

In accordance with Section 18.2.2.2.6; any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure (except boiler rooms, heater rooms, and mechanical equipment rooms) shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility. Finally, Annex A.18.2.2.2.6 states that it is desirable to keep doors in exit passageways, stair enclosures, horizontal exits, smoke barriers, and required enclosures around hazardous areas closed at all times to impede the travel of smoke and fire gases. Functionally, however, this involves decreased efficiency and limits patient observation by the staff of an institution. To accommodate such needs, it is practical to presume that such doors will be kept open, even to the extent of employing wood chocks and other makeshift devices. Doors in exit passageways, horizontal exits, and smoke barriers should, therefore, be equipped with automatic hold-open devices activated by the methods described, regardless of whether the original installation of the doors was predicated on a policy of keeping them closed.

The smoke barrier door at radiology was observed at 2:11 p.m. on 6/20/12. The door was being held open with a chock.

Based on observation on June 19, and 20, 2012, the facility failed to provide doors on hazardous areas which closed to a smoke tight surface and doors for hazardous areas which met the intent of the Code.

Findings include:

1. The elevator maintenance room in the hospital was observed at 1:10 p.m. on 6/19/12. The hydraulic fluid line extended through the east wall and was not properly sealed.

Section 8.4.1.3 states that doors in barriers required to have a fire resistance rating shall have a 3/4 hour fire protection rating and shall be self-closing in accordance with 7.2.1.8.

2. The medical records storeroom in the basement was observed at 1:30 p.m. on 6/19/12. A large access hole (30 inches by 30 inches) was left unsealed between the storeroom and the crawl space beneath the hospital which is unsprinkled. There was no rated door covering this access space.

Based on observation on June 19, and 20, 2012, the facility failed to provide doors on hazardous areas which closed to a smoke tight surface, maintain the rating of 1 hour walls, and maintain doors for hazardous areas.

Findings include:

In accordance with NFPA 101 and section 19.3.2.1 Hazardous Areas, any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have non-rated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Section 8.4.1.3 of NFPA 101, Life Safety Code states that doors in barriers required to have a fire resistance rating shall have a 3/4 hour fire protection rating and shall be self-closing in accordance with 7.2.1.8.

1. The old basement storeroom was observed at 1:50 p.m. on 6/19/12. The following deficiencies were noted:
a) Twenty penetrations were either unsealed or sealed with building foam, which does not meet the requirements for a 1-hour rated wall.
b) The large heating ventilation and air-conditioning (HVAC) supply and return air were not properly sealed where they enter the crawl space.
c) The fire rated doors into the crawl spaces were not latched as an extension cord was run through the doors.

2. The compressor room was observed at 2:00 p.m. on 6/19/12. There were two penetrations above the door from the boiler room which were not sealed.

3. The wall between the compressor room and the boiler room was observed at 2:00 p.m. on 6/19/12. There were four penetrations in the wall which were unsealed.

4. The boiler room of the hospital was observed at 2:00 p.m. on 6/19/12. The following deficiencies were noted:
a) There were five open penetrations between the boiler room which was separated with 2-hour barrier and the adjoining storeroom which was a 1-hour rating.
b) There were also five penetrations between the boiler room and the air-conditioner room, which was also one-hour rated.

5. The air-conditioner room near the boiler room was observed at 2:10 p.m. on 6/19/12. There were six penetrations of the corridor wall which were not sealed.

6. The storeroom housing the medical air equipment was observed at 7:50 a.m. on 6/20/12. There was one penetration in the north wall for electrical wiring.

7. The generator room was observed at 7:51 a.m. on 6/20/12. There was one penetration in the north wall of this room for a sprinkler pipe.

Based on observation on June 20, 2012, the facility failed to provide doors on hazardous areas which were self closing.

Findings include:

In accordance with Section 18.3.2.1; any hazardous area shall be protected in accordance with Section 8.4. Section 8.4.1.3 of NFPA 101, Life Safety Code states that doors in barriers required to have a fire resistance rating shall have a 3/4 hour fire protection rating and shall be self-closing in accordance with 7.2.1.8.

The materials management area and office space was observed at 8:28 a.m. on 6/20/12. The door between the office and the storeroom was not self-closing.

Based on observations made on June 19, 2012 the facility failed to maintain the existing width of an exit corridor.

Findings include:

In accordance with 4.6.7 of the Life Safety Code corridors that were originally designed and code approved to be 8 feet in width cannot be reduced in width.

The exit corridor system for the basement of the Hospital was observed at 2:00 p.m. on 6/19/12. There was an abundance of stored items in the exit corridors in the basement including files, chairs, desks, furniture, etc. The Health Works Fitness Center was used by high school training classes and this amount of stored items in the corridor system could affect exiting in cases of emergency.

Based on observation on June 19, 2012, the facility failed to maintain battery pack emergency lighting in Suite 110.

Findings include:
In accordance with 39.2.8 Illumination of Means of Egress.
Means of egress shall be illuminated in accordance with Section 7.8.

Clinic suite 110 was observed at 10:00 a.m. on 6/19/2012. The battery pack style emergency light fixture was tested and the fixture failed to illuminate.

Based on observation made on June 19, 2012, the facility failed to ensure that the breaker which controlled the fire alarm control panel was permanently marked in red.

Findings include:

In accordance with Section 1-5.2.5.2 of NFPA 72, (1999 edition); the connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

The FACP and connecting services were reviewed at 10:00 a.m. on 6/20/2012. The Simplex 4100 FACP located on the wall directly across from the hospital nurse's station was identified as to what dedicated power circuit branch provided power for it with the breaker and panel numbers; however, when viewing the electric panel which served the FACP, the breaker was not identified in RED.

Based on observation on June 19, 2012, the facility did not ensure complete coverage of the building by an approved automatic sprinkler system.

Findings include:

The outpatient surgery area of the hospital was observed at 4:20 p.m. on 6/19/12. A three foot by four foot area near the ice machine has short walls which extend out from walls which block off the installed sprinkler pattern. There is no sprinkler head which covers an alcove small area near the ice-machine.

Based on observation, the facility did not ensure complete coverage of the building by an approved automatic sprinkler system.

Findings include:

The stairway from the boiler room to D-wing was observed at 2:01 p.m. on 6/19/12. The stairway used to go to the outside of the building, but has now been enclosed and is not sprinkled by the present sprinkler system.

Based on record review and observations that were made on June 19 and 20, 2012, the facility failed to maintain the sprinkler system in accordance with NFPA 25, 1998 Edition.

The findings include:

All control valves shall be inspected to verify that the valves are in the following condition per section 9-3.3.2 of NFPA 25:
(a) In the normal open or closed position
(b) Properly sealed, locked, or supervised
(c) Accessible
(d) Provided with appropriate wrenches
(e) Free from external leaks
(f) Provided with appropriate identification

1. The valves which control the anti-freeze loops on the sprinkler risers were observed to be not supervised as the locks were not locked at observed at 9:25 a.m. on 6/19/12.

2. The sprinkler quarterly reports were reviewed at 9:30 a.m. on 6/19/12. They also indicated that the antifreeze valves were not supervised by lock or interconnected to the fire alarm.

Based on observation, the facility failed to maintain the sprinkler system and its components in accordance with the standards of NFPA 13, 1999 Edition.

The findings include:

In accordance with NFPA 13 and Section 3-2.7.2; escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. Further guidance in Annex A-3-2.7.2 states that the use of the wrong type of escutcheon with recessed or flush-type sprinklers can result in severe disruption of the spray pattern, which can destroy the effectiveness of the sprinkler.

1. Suite 111 of the Clinic was observed at 10:10 a.m. on 6/19/2012. An escutcheon ring was missing on the ceiling of this suite.

2. Suite 108 in the Clinic was observed at 10:12 a.m. on 6/19/2012. An escutcheon ring was missing in the bathroom of this suite.

3. The north end corridor space of the Clinic was observed at 11:45 a.m. on 6/19/2012. An escutcheon ring was missing in the corridor next to the double doors to the hospital.

Based on review of the sprinkler service and inspection reports on June 19 and 20, 2012, the facility failed to assure that the backflow preventer device(s) for the sprinkler system had been tested on an annual basis in accordance with NFPA 25, 1998 Edition.

The findings include:

All backflow preventers installed in fire protection system piping shall be tested annually per section 9-6.2.1 of NFPA 25 in accordance with the following:
(a) A forward flow test shall be conducted at the system demand, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer.
(b) A backflow performance test, as required by the authority having jurisdiction, shall be conducted at the completion of the forward flow test.
Exception No. 1: For backflow preventers sized 2 in. (50.8 mm) and under, it shall be acceptable to conduct the forward flow test without measuring flow, where the test outlet is of a size to flow the system demand.
Exception No. 2: Where water rationing shall be enforced during shortages lasting more than 1 year, an internal inspection of the backflow preventer to ensure the check valves will fully open shall be acceptable in lieu of conducting the annual forward flow test.
Exception No. 3: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be completed at the maximum flow rate possible.
Exception No. 4: The forward flow test shall not be required where annual fire pump testing causes the system demand to flow through the backflow preventer device.

The sprinkler service and inspection reports were reviewed at 1:10 p.m. on 6/19/2012 at the facility. The reports examined did not contain verification that the backflow preventer device(s) had been tested on an annual basis as required by NFPA 25.

Based on review of the sprinkler service and inspection reports on June 19 and 20, 2012, the facility failed to maintain the sprinkler system and all its components in accordance with the standards of NFPA 25, 1998 Edition and NFPA 13, 1999 Edition.

Findings include:

In accordance with NFPA 25 and Section 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.

1. The sprinkler heads throughout the kitchen (more than 10) were full of lint as observed at 3:25 p.m. on 6/19/12.

In accordance with NFPA 13 and Section 3-2.7.2; escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. Further the in Annex A-3-2.7.2 the guidance is that the use of the wrong type of escutcheon with recessed or flush-type sprinklers can result in severe disruption of the spray pattern, which can destroy the effectiveness of the sprinkler.

2. An escutcheon ring was missing in the corridor near the network storeroom as observed at 3:33 p.m. on 6/19/12.

Based on surveyor observations made on June 19 and 20, 2012, the facility failed to maintain the sprinkler system and all its components in accordance with the standards of NFPA 13, 1999 Edition.

Findings include:

In accordance with NFPA 13 and Section 3-2.7.2; escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. Further the in Annex A-3-2.7.2 the guidance is that the use of the wrong type of escutcheon with recessed or flush-type sprinklers can result in severe disruption of the spray pattern, which can destroy the effectiveness of the sprinkler.

1. There was an escutcheon ring missing on the dirty side of CSR as observed at 4:00 p.m. on 6/19/12.

2. An escutcheon ring was missing on the ceiling of the materials management office as observed at 8:30 a.m. on 6/20/12.

Based on surveyor observations made on June 19, 2012, the facility failed to maintain the sprinkler system and all its components in accordance with the standards of NFPA 25, 1998 Edition.

Findings include:

In accordance with NFPA 13 and Section 3-2.7.2; escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly. Further the in Annex A-3-2.7.2 the guidance is that the use of the wrong type of escutcheon with recessed or flush-type sprinklers can result in severe disruption of the spray pattern, which can destroy the effectiveness of the sprinkler.

1. There was an escutcheon ring missing on the ceiling of the woodshop as observed at 1:20 p.m. on 6/19/12.

2. There was an escutcheon ring missing on the ceiling of the exit corridor near the kitchen exit as observed at 2:35 p.m. on 6/19/12.

Based on observations made on June 19, 2012, the facility did not ensure portable fire extinguishers were mounted in accordance with the standards of NFPA 10.

Findings include:

In accordance with NFPA 10, 1998 Edition, and section 4-3.2; periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility

Additionally, in accordance with 1-6.7 and 1-6.10 of NFPA 10, (1998 edition); portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet (60 Inches) above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet (42 inches) above the floor.

The pathology department was observed at 4:15 p.m. on 6/19/12. The portable fire extinguisher was sitting in a corner atop a counter and not installed/mounted on a wall accessible to anyone who could possibly use it. The top of the extinguisher was at 68 inches above the floor.

Based on observation and staff interview on June 19, 2012, the facility did not ensure that oxygen cylinders were supported from falling over while in storage.

Findings include:

In accordance with sections 8-3.1.11.2(h) and 4-3.5.2.1 (b27) of NFPA 99 (1999 edition), freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

The maintenance shop in the basement of the hospital was observed at 1:00 p.m. on 6/19/12. There were two oxygen cylinders sitting near the back wall of the shop which had not been properly secured.

Based on observation on June 20, 2012, the facility did not ensure that oxygen cylinders were supported from falling over while in storage.

Findings include:

In accordance with sections 8-3.1.11.2(h) and 4-3.5.2.1 (b27) of NFPA 99 (1999 Edition), freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

The main oxygen store room for the hospital was observed at 8:10 a.m. on 6/20/12. There were four oxygen cylinders which had not been properly secured behind chains.

Based on observation and record review on June 19 and 20, 2012, the facility failed to to maintain the reserve oxygen supply, provide the oxygen system with duplex final line pressure regulator and ensure area alarms functioned properly. These deficiencies were per the March 28, 2012 Piped Medical Gas System Evaluation by an outside contractor.

Findings include:

1. In accordance with NFPA 99, 1999 Edition and Section 4-3.1.1.6(b); the reserve supply shall consist of three or more manifolded high-pressure cylinders connected as required under 4-3.1.1.8(b), and either shall be equipped with check valves as required in 4-3.1.1.5(b) or shall be provided with an actuating switch that shall operate the master signals when the reserve supply drops to one day ' s supply.

The reserve bank for the oxygen supply tank was reading 200 psig which is virtually empty per the March 28, 2012 Piped Medical Gas System Evaluation by an outside contractor.

2. In accordance with Section 4-3.1.1.8 (1) (g) of NFPA 99 (1999 Edition); final line regulators shall be duplexed with suitable valving to permit service to the regulators without completely shutting down the gas piping system.

The bulk oxygen systems were observed and reviewed at 8:10 a.m. on 6/20/12. The Oxygen system have only one final line regulator. By Code, they are to be duplexed with suitable valving to permit service on the regulators without completely shutting down the gas piping system.

3. In accordance wih NFPA 99 and Section 4-3.1.2.2 (b.), cancelable audible indication of an alarm condition. The audible indicator shall produce a minimum of 80 dBA measured at 3 ft (1 m). A second indicated condition occurring while the alarm is silenced shall reinitiate the audible signal. Further Section 4-3.1.2.2(e), indicated that the scale range of positive pressure analog gauges shall be such that the normal reading falls within the middle 50 percent of the scale. The scale range of digital gauges shall be not more than two times the working pressure. The rated accuracy of pressure gauges used for testing shall be one percent (full scale) or better at the point of reading. Pressure gauges shall be in compliance with ANSI/ASME B-40.1, Gauges, Pressure Indicating Dial-Type, Elastic Elements.

The following deficiencies were noted by per the March 28, 2012 Piped Medical Gas System Evaluation by an outside contractor:
a) the area alarm outside room 305 in OB had an oxygen signal which failed to silence when tested, and
b) there was a problem with the area alarm panel in OR-2 as the panel only indicated pressure up to 122 psig.

Based on observation and record review June 19, 2012, all of the anesthetizing locations were not protected in accordance with NFPA 99, Standard for Health Care Facilities per the March 28, 2012 Piped Medical Gas System Evaluation by an outside contractor.


In accordance with Section 4-3.1.2.3 (n) of NFPA 99 (1999 Edition); a shutoff valve shall be located outside each anesthetizing location in each medical gas line, so located as to be readily accessible at all times for use in an emergency. These valves shall be so arranged that shutting off the supply of gas to any one operating room or anesthetizing location will not affect the others. Valves shall be of an approved type, mounted on a pedestal or otherwise properly safeguarded against physical damage, and marked in accordance with 4-3.5.4.2.

Finding include:

The annual report for the Piped Medical Gas System Evaluation was reviewed at 10:30 a.m. on 6/19/12. The report indicated that the zone valves in rooms 305 and 306 of OB are controlled by inline valves and would affect other areas when turned off. Further, the report indicated that conditions exist where a potential problem could arise if action is not taken in the future.

Based on observation on June 19, 2012, the facility failed to meet the standards of either NFPA 70 in regards to electrical service in the building.

Findings include:

In accordance with Section 39.5.1 Utilities; utilities shall comply with the provisions of Section 9.1. Section 9.1.2 states that electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

In accordance with Article 110-27(b); in locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage.

1. Exam rooms 2 and 3 in Suite 108 were observed at 10:20 a.m. on 6/19/2012. There were heating pads plugged into wall outlets which were then inserted into drawers which were closed on the cords.

In accordance with Article 370-25, in completed installations, each box shall have a cover, faceplate, or fixture canopy.

2. The cleaning room in Suite 101 was observed at 10:45 a.m. on 6/19/2012. An electrical outlet cover was missing in this room.

Based on observations made on June 19 and 20, 2012, the facility failed to maintain the electrical system in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS).

The findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions per Article 240-4(b)(3) of NFPA 70 or by interpretations issued by the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings.

1. The old basement storeroom was observed at 2:00 p.m. on 6/19/12. An extension cord was in-use to power a paging system. (Note: the cord was removed at the time of the survey process.)

2. The pharmacy was observed at 3:05 p.m. on 6/19/12. Two surge cords were found connected in series for the OPHUS cart system.

3. The case management office was observed at 8:35 a.m. on 6/20/12. There were 2 extension cords in-use under desks. (Note: the cords were removed at the time of the survey process).

4. The network room in the medical surgical patient area was observed at 8:40 a.m. on 6/20/12. An electrical cover was missing in this room.

5. The sleep study office was observed at 9:00 a.m. on 6/20/12. There were 2-surge cords found in series.

6. The information technology (IT) office was observed at 9:20 a.m. on 6/20/12. An extension cord was found in-use in this room.

7. The business office areas were observed at 9:25 a.m. on 6/20/12. There were 2 multi-plug adaptors in use in this area.

8. The X-Ray work area was observed at 10:15 a.m. on 6/20/12. There were 2 surge cords not mounted to the wall, but dangled by the cord. Also, there were 2 surge cords plugged in series in this work area.

9. The respiratory therapy office area was observed at 10:35 a.m. on 6/20/12. There were 2 surge cords not mounted to the wall. Also, a microwave oven was plugged into a surge cord.

10. The radiology work areas were observed at 2:10 p.m. on 6/20/12. One surge cord extended through a doorway of a smoke barrier, and the door in the barrier would not close.

Based on observations made on June 20, 2012, the facility failed to maintain the electrical system in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS).

The findings include:

The intensive care unit was observed at 8:36 a.m. on 6/20/12. One surge cord was found not laying flat on the floor or mounted to the wall, but was dangling by the cord.