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Based on observation and staff interview, the facility failed to provide 2-hour rated construction at the building separation walls in accordance with 2000 - NFPA 101, sections 19.1.1.4, 19.1.2.3 and 8.2.3.2.


Findings include:

On facility tour between 9: 00 AM and 3:30 PM on 03/24/2015, observation revealed the following in the 2-hour fire rated building separation walls between the following locations:

1. Hospital and the ambulance garage, wall penetrations were observed on wall between the ambulance garage and the hospital.

2. Hospital and the clinic, there are open penetrations above the ceiling panels.


These deficient practices were confirmed by the Director of Maintenance (JB) at the time of discovery.

Based on observations and staff interview, the facility had a penetration in the corridors that is not in compliance with NFPA Life Safety Code 101 (00) Sections 19.3.6.2 and 8.2.4.4.1 in resisting the passage of smoke.

Findings include:

On facility tour between 9: 00 AM and 3:30 PM on 03/24/2015, observation revealed the wall across from the Ambulance Garage door has open penetrations below the ceiling.


These deficient practices were confirmed by the Director of Maintenance (JB) at the time of discovery.

Based on observation and staff interview, the facility had a corridor door that did not latch into their frames in accordance with the requirements of 2000 NFPA 101, Sections 19.3.6.3.2.

Findings include:
On facility tour between 9:00 AM and 3:30 PM on 03/24/2015, observation revealed the North Cafeteria Door going into the corridor is not positive latching.

This deficient practice was confirmed by the Director of Maintenance (JB) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain hazardous area in accordance with the following requirements of 2000 NFPA 101, Section 8.4.1 and/or 19.3.5.4.


Findings include:

On facility tour between 9:00 AM and 3:30 PM on 03/24/2015, observation revealed that the following items were found for the East Wing Linen/Storage Room (over 50 sq ft):

1. The room is not protected by a fire sprinkler and does not have a fire rated door;
2. The door does not self close/latch


These deficient practices were confirmed by the Facility Maintenance Director (JB) at the time of discovery.

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Section 3-8.4.1.3.5.1. This deficient condition could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.


Findings include:


On facility tour between 9:00 AM and 3:30 PM on 03/24/2015, observations revealed

1: The facility's fire alarm control panel (F.A.C.P.) is located in the Hospital Boiler room in an area that is not continuously occupied and there is no remote station at a 24 hour location.

2: There was no automatic smoke detector with sounder base present in the M.D. Resident Sleeping Room.


These deficient practices were confirmed by the Facility Maintenance Director (JB) at the time of discovery.

Based on observation and staff interview, the facility failed to assure the pipe medical gas system is labeled and tested as required by 1999 NFPA 99 Chapter 4-3.5.2.3 (i).

Findings include:

On facility tour between 9:00 AM and 3:30 PM on 03/24/2015, the review of the medical gas alarm system revealed, that there is no documentation for testing of the audible and visual alarm indicators in the past 12 months.

This deficient practice was confirmed by Director of Facility Maintenance (JB) at the time of discovery.

Based on observation and staff interview, the facility failed to provide 2-hour rated construction at the building separation walls in accordance with 2000 - NFPA 101, sections 19.1.1.4, 19.1.2.3 and 8.2.3.2.


Findings include:

On facility tour between 9: 00 AM and 3:30 PM on 03/24/2015, observation revealed the following in the 2-hour fire rated building separation walls between the following locations:

1. Hospital and the ambulance garage, wall penetrations were observed on wall between the ambulance garage and the hospital.

2. Hospital and the clinic, there are open penetrations above the ceiling panels.


These deficient practices were confirmed by the Director of Maintenance (JB) at the time of discovery.

Based on observations and staff interview, the facility had a penetration in the corridors that is not in compliance with NFPA Life Safety Code 101 (00) Sections 19.3.6.2 and 8.2.4.4.1 in resisting the passage of smoke.

Findings include:

On facility tour between 9: 00 AM and 3:30 PM on 03/24/2015, observation revealed the wall across from the Ambulance Garage door has open penetrations below the ceiling.


These deficient practices were confirmed by the Director of Maintenance (JB) at the time of discovery.

Based on observation and staff interview, the facility had a corridor door that did not latch into their frames in accordance with the requirements of 2000 NFPA 101, Sections 19.3.6.3.2.

Findings include:
On facility tour between 9:00 AM and 3:30 PM on 03/24/2015, observation revealed the North Cafeteria Door going into the corridor is not positive latching.

This deficient practice was confirmed by the Director of Maintenance (JB) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain hazardous area in accordance with the following requirements of 2000 NFPA 101, Section 8.4.1 and/or 19.3.5.4.


Findings include:

On facility tour between 9:00 AM and 3:30 PM on 03/24/2015, observation revealed that the following items were found for the East Wing Linen/Storage Room (over 50 sq ft):

1. The room is not protected by a fire sprinkler and does not have a fire rated door;
2. The door does not self close/latch


These deficient practices were confirmed by the Facility Maintenance Director (JB) at the time of discovery.

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Section 3-8.4.1.3.5.1. This deficient condition could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.


Findings include:


On facility tour between 9:00 AM and 3:30 PM on 03/24/2015, observations revealed

1: The facility's fire alarm control panel (F.A.C.P.) is located in the Hospital Boiler room in an area that is not continuously occupied and there is no remote station at a 24 hour location.

2: There was no automatic smoke detector with sounder base present in the M.D. Resident Sleeping Room.


These deficient practices were confirmed by the Facility Maintenance Director (JB) at the time of discovery.

Based on observation and staff interview, the facility failed to assure the pipe medical gas system is labeled and tested as required by 1999 NFPA 99 Chapter 4-3.5.2.3 (i).

Findings include:

On facility tour between 9:00 AM and 3:30 PM on 03/24/2015, the review of the medical gas alarm system revealed, that there is no documentation for testing of the audible and visual alarm indicators in the past 12 months.

This deficient practice was confirmed by Director of Facility Maintenance (JB) at the time of discovery.