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Based on observation and staff interview, the facility failed to ensure 1 of 2 fire barriers had rated doors. The findings were:

Observation of the second floor fire barrier on 9/21/11 at 12:25 PM showed the double doors did not have labels indicating their fire rating. At the time of observation maintenance technician #1 reported he was aware the doors were required to have a 1 1/2 hour fire rating. He also reported the labels had been removed and nails marks were visible where the labels had been.

Reference:
NFPA 101, 2000 Edition;
19.1.1.4.1 Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. (See 4.6.11 and 4.6.6.)
19.1.1.4.2 Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors. (See also Section 8.2.)

Based on observation and staff interview, the facility failed to ensure walls and ceilings were smoke resistant in 3 of 13 smoke compartments. The findings were:

Observation on 9/21/11 between 10 AM and 12:30 PM showed the first floor telephone room, the first floor level lock closet, and the second floor housekeeping closet had unsealed wall and ceiling penetrations. The largest gap measured 6 inches across. At 10:37 AM maintenance technician #1 could not explain why the holes had not been noticed and repaired during the semi-annual inspections.

Reference:
NFPA 101, 2000 Edition;
19.1.6.4 Each exterior wall of frame construction and all interior stud partitions shall be firestopped to cut off all concealed draft openings, both horizontal and vertical, between any cellar or basement and the first floor. Such firestopping shall consist of wood not less than 2 in. (5 cm) (nominal) thick or shall be of noncombustible material.

Based on observation and staff interview, the facility failed to ensure corridor doors were smoke resistant in 1 of 13 smoke compartments. The findings were:

Observation of patient room #315 on 9/21/11 at 1:58 PM showed the corridor door latch bolt was not able to insert into the door frame strike plate. At the time of observation maintenance technician #1 could not explain why the door had not been identified and repaired during the monthly inspections.

Based on observation and staff interview, the facility failed to ensure 3 of 14 smoke barrier walls were smoke resistant. The findings were:

Observation of smoke barrier walls on 9/21/11 between 3 PM and 4 PM showed the fourth floor west barrier, the second floor elevator lobby barrier, and the first floor lobby barrier had unsealed penetrations. The largest gap measured 3/4 of an inch across. Interview with the maintenance technician #1 at the time of the observation revealed he could not explain why the holes had not been identified and repaired during the quarterly inspections.

Based on observation and staff interview, the facility failed to ensure hazardous areas were separated from use areas in 1 of 13 smoke compartments. The findings were:

Observation of the fourth floor power room on 9/21/11 at 2:59 PM showed there were five unsealed cable penetrations. The largest hole measured 5 inches across. At the time of observation maintenance technician #1 could not explain why the holes had not been identified and repaired during the quarterly inspections.

Based on observation and staff interview, the facility failed to ensure smoke detectors had proper spacing in 1 of 13 smoke compartments. The findings were:

Observation of the fire alarm system on 9/21/11 between 11:30 AM and 12 PM showed the smoke detectors in Wellness room #208 and the physicians' change room were located less than 36 inches from the ventilation diffuser. Both smoke detectors were located 12 inches from the diffusers. At the time of observation maintenance technician #1 reported he was not aware of the aforementioned spacing requirement. He also reported the remodel of this area was completed in September 2008.

Reference:
NFPA 101, 2000 Edition, 18.3.4.1, 9.6.1.4 , NFPA 72, 1999 Edition;
5.7.4.1* In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.
A 5.7.4.1 Detectors should not be located in a direct airflow or closer than 1 m (3 ft) from an air supply diffuser or return air opening ...

Based on observation and staff interview, the facility failed to ensure sprinklers were unobstructed in 2 of 13 smoke compartments. The findings were:

1. Observation of the closet in the medical records office on 9/21/11 at 10:10 AM showed items were stored less than 18 inches below the sprinkler deflector. The items were stored 6 inches below the deflector. At the time of observation maintenance technician #1 reported he was aware of the aforementioned spacing requirement. Furthermore he reported the medical records areas was not routinely inspected.

2. Observation of cafeteria corridor on 9/21/11 at 10:43 AM showed a sprinkler head was obstructed by the information sign. Further observation showed the sprinkler deflector was located 20 inches from and 7 inches above the bottom of the sign. At the time of observation maintenance technician #1 reported he was aware of the aforementioned spacing requirement.

Reference:
NFPA 101, 2000, 19.3.5.1, 9.7.1.1, NFPA 13, 1999 Edition;
5-5.6 Clearance to storage. The clearance between the deflector and the top of storage shall be 18 in. or greater.
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (Standard Spray Upright/Standard Spray Pendent)

Maximum allowable
Distance from distance from
sprinkler to side deflector above
of obstruction bottom of obstruction
-------------------------------------------------------
Less than 1 ft ... ... ... ... ... ... ............. ....0
1 ft to less than 1 ft 6 in. ... ... ... ... ... ...2 ?
1 ft 6 in. to less than 2 ft .... ... ... ... ......3 ?
2 ft to less than 2 ft 6 in. ...... ... ... ... ...5 ?
2 ft 6 in. to less than 3 ft ... ... ... ...........7 ?
3 ft to less than 3 ft 6 in ... ... .... ... ... ...9 ?
3 ft 6 in. to less than 4 ft ... ... ... ... ... ...12

Based on observation and staff interview, the facility failed to ensure electrical outlets in wet locations had ground fault circuit interruption (GFCI) protection and failed to ensure temporary wiring did not replace permanent fixed wiring in 4 of 10 smoke compartments. The findings were:

1. Observation of the electrical system on 9/21/11 between 10 AM and 1 PM showed the electrical outlets in the pharmacy, sterile processing, and lab blood bank room were located less than 72 inches from a sink and did not have GFCI protection. At 10:11 AM maintenance technician #1 reported he was unaware existing outlets in wet locations were required to have GFCI protection.

2. Observation of the electrical system on 9/21/11 between 11 AM and 3 PM showed the lamp in the physicians' lounge and the refrigerator in the fourth floor suite #5 room were plugged into extension cords. At 11:23 AM maintenance technician #1 could not explain why the extension cords had not been identified and removed during the quarterly electrical inspections.

Reference:
NFPA 101, 2000 Edition, 19.5.1, 9.1.2, NFPA 70, 1999 Edition;
400-8. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls ...
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
517-20. Wet Locations.
(a) All receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection for personnel if interruption or power under fault conditions can be tolerated, or be served by an isolated power system if such interruption cannot be tolerated.

Based on observation and staff interview, the facility failed to ensure 1 of 2 fire barriers had rated doors. The findings were:

Observation of the second floor fire barrier on 9/21/11 at 12:25 PM showed the double doors did not have labels indicating their fire rating. At the time of observation maintenance technician #1 reported he was aware the doors were required to have a 1 1/2 hour fire rating. He also reported the labels had been removed and nails marks were visible where the labels had been.

Reference:
NFPA 101, 2000 Edition;
19.1.1.4.1 Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. (See 4.6.11 and 4.6.6.)
19.1.1.4.2 Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire doors. (See also Section 8.2.)

Based on observation and staff interview, the facility failed to ensure walls and ceilings were smoke resistant in 3 of 13 smoke compartments. The findings were:

Observation on 9/21/11 between 10 AM and 12:30 PM showed the first floor telephone room, the first floor level lock closet, and the second floor housekeeping closet had unsealed wall and ceiling penetrations. The largest gap measured 6 inches across. At 10:37 AM maintenance technician #1 could not explain why the holes had not been noticed and repaired during the semi-annual inspections.

Reference:
NFPA 101, 2000 Edition;
19.1.6.4 Each exterior wall of frame construction and all interior stud partitions shall be firestopped to cut off all concealed draft openings, both horizontal and vertical, between any cellar or basement and the first floor. Such firestopping shall consist of wood not less than 2 in. (5 cm) (nominal) thick or shall be of noncombustible material.

Based on observation and staff interview, the facility failed to ensure corridor doors were smoke resistant in 1 of 13 smoke compartments. The findings were:

Observation of patient room #315 on 9/21/11 at 1:58 PM showed the corridor door latch bolt was not able to insert into the door frame strike plate. At the time of observation maintenance technician #1 could not explain why the door had not been identified and repaired during the monthly inspections.

Based on observation and staff interview, the facility failed to ensure 3 of 14 smoke barrier walls were smoke resistant. The findings were:

Observation of smoke barrier walls on 9/21/11 between 3 PM and 4 PM showed the fourth floor west barrier, the second floor elevator lobby barrier, and the first floor lobby barrier had unsealed penetrations. The largest gap measured 3/4 of an inch across. Interview with the maintenance technician #1 at the time of the observation revealed he could not explain why the holes had not been identified and repaired during the quarterly inspections.

Based on observation and staff interview, the facility failed to ensure hazardous areas were separated from use areas in 1 of 13 smoke compartments. The findings were:

Observation of the fourth floor power room on 9/21/11 at 2:59 PM showed there were five unsealed cable penetrations. The largest hole measured 5 inches across. At the time of observation maintenance technician #1 could not explain why the holes had not been identified and repaired during the quarterly inspections.

Based on observation and staff interview, the facility failed to ensure smoke detectors had proper spacing in 1 of 13 smoke compartments. The findings were:

Observation of the fire alarm system on 9/21/11 between 11:30 AM and 12 PM showed the smoke detectors in Wellness room #208 and the physicians' change room were located less than 36 inches from the ventilation diffuser. Both smoke detectors were located 12 inches from the diffusers. At the time of observation maintenance technician #1 reported he was not aware of the aforementioned spacing requirement. He also reported the remodel of this area was completed in September 2008.

Reference:
NFPA 101, 2000 Edition, 18.3.4.1, 9.6.1.4 , NFPA 72, 1999 Edition;
5.7.4.1* In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.
A 5.7.4.1 Detectors should not be located in a direct airflow or closer than 1 m (3 ft) from an air supply diffuser or return air opening ...

Based on observation and staff interview, the facility failed to ensure sprinklers were unobstructed in 2 of 13 smoke compartments. The findings were:

1. Observation of the closet in the medical records office on 9/21/11 at 10:10 AM showed items were stored less than 18 inches below the sprinkler deflector. The items were stored 6 inches below the deflector. At the time of observation maintenance technician #1 reported he was aware of the aforementioned spacing requirement. Furthermore he reported the medical records areas was not routinely inspected.

2. Observation of cafeteria corridor on 9/21/11 at 10:43 AM showed a sprinkler head was obstructed by the information sign. Further observation showed the sprinkler deflector was located 20 inches from and 7 inches above the bottom of the sign. At the time of observation maintenance technician #1 reported he was aware of the aforementioned spacing requirement.

Reference:
NFPA 101, 2000, 19.3.5.1, 9.7.1.1, NFPA 13, 1999 Edition;
5-5.6 Clearance to storage. The clearance between the deflector and the top of storage shall be 18 in. or greater.
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (Standard Spray Upright/Standard Spray Pendent)

Maximum allowable
Distance from distance from
sprinkler to side deflector above
of obstruction bottom of obstruction
-------------------------------------------------------
Less than 1 ft ... ... ... ... ... ... ............. ....0
1 ft to less than 1 ft 6 in. ... ... ... ... ... ...2 ?
1 ft 6 in. to less than 2 ft .... ... ... ... ......3 ?
2 ft to less than 2 ft 6 in. ...... ... ... ... ...5 ?
2 ft 6 in. to less than 3 ft ... ... ... ...........7 ?
3 ft to less than 3 ft 6 in ... ... .... ... ... ...9 ?
3 ft 6 in. to less than 4 ft ... ... ... ... ... ...12

Based on observation and staff interview, the facility failed to ensure electrical outlets in wet locations had ground fault circuit interruption (GFCI) protection and failed to ensure temporary wiring did not replace permanent fixed wiring in 4 of 10 smoke compartments. The findings were:

1. Observation of the electrical system on 9/21/11 between 10 AM and 1 PM showed the electrical outlets in the pharmacy, sterile processing, and lab blood bank room were located less than 72 inches from a sink and did not have GFCI protection. At 10:11 AM maintenance technician #1 reported he was unaware existing outlets in wet locations were required to have GFCI protection.

2. Observation of the electrical system on 9/21/11 between 11 AM and 3 PM showed the lamp in the physicians' lounge and the refrigerator in the fourth floor suite #5 room were plugged into extension cords. At 11:23 AM maintenance technician #1 could not explain why the extension cords had not been identified and removed during the quarterly electrical inspections.

Reference:
NFPA 101, 2000 Edition, 19.5.1, 9.1.2, NFPA 70, 1999 Edition;
400-8. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls ...
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
517-20. Wet Locations.
(a) All receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection for personnel if interruption or power under fault conditions can be tolerated, or be served by an isolated power system if such interruption cannot be tolerated.