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Based on observations the facility failed to provide smoke barriers that were constructed with at least a one hour fire resistance rating for 2 of 3 walls as per National Fire Protection Association (NFPA) 101 (Life Safety Code). This deficiency affects 3 of 4 smoke compartments and any patient that comes in to the ER or stays overnight in the facility.

Note: NFPA 101, 2000 edition:
NFPA 101: 18.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.

Findings:

During facility tour on July 9, 2012 between 9:00 a.m. and 12:00 p.m., the integrity of the smoke barrier wall was observed to be compromised in the following areas.

1. There was a three inch conduit with a bundle of wires in it that is penetrating the smoke barrier wall between room 301 and the outpatient Pharmacy that is not sealed.
2. There was a one inch conduit that is penetrating the smoke barrier wall between room 301 and the outpatient Pharmacy that is not sealed.
3. Above the cross corridor doors between room 301 & the outpatient Pharmacy a piece of drywall around the roof joist is coming off and leaving a gap in the wall.
4. There is a gap between the drywall and the roof joist at the 400 hall smoke barrier that is not sealed.

Based on observation the facility failed to provide door to smoke barriers that close fully in accordance with National Fire Protection Association (NFPA) 101 (Life Safety Code). This deficiency affects 3 of 3 smoke barriers, 4of 4 smoke compartments and any patient that use the ER or stays overnight in the facility.

Note: NFPA 101, 2000 edition:
NFPA 101:18.2.2.2.6 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.

Findings:

During a tour of the facility on July 9, 2012 between 9:00 a.m. and12:00 p.m. it was observed that the following doors were not closing completely or resisting the passage of smoke. When the fire alarm system was activated the magnetic holding device did release the doors, but the doors did not close fully in the following areas.

1. The doors to the smoke barrier between the outpatient Pharmacy and room 301 are dragging on the frame preventing the doors from closing completely.
2. The door frame of the smoke barrier between the outpatient Pharmacy and room 301 has a 1 ½ inch by 1 ½ inch hole at the edge of the door jamb where the doors meet that is not sealed.
3. All three set of smoke barriers doors have a gap between the doors that would not resist the passage of smoke.

Based on observation and review of documentation, the facility failed to have the fire alarm system fully operational as per National Fire Protection Association (NFPA) 72 (National Fire Alarm Code) and NFPA 101 (Life Safety Code) for 1 of 1 system. This deficiency affects any patient that uses the ER or stays overnight in the facility.

Note: NFPA 101, 2000 edition:
NFPA 101: 9.6.1.4
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

Findings:

An observation was made on July 9, 2012 at 9:30 a.m. of the fire alarm system. Review of the annual inspection report (dated 4-12-12) revealed that the smoke detector in the staff lounge is not working properly and that three of the roof top A/C units do not have duct detectors in them.

Based on review of documentation the facility failed to provide routine inspection, testing and maintenance of the sprinkler system as per NFPA 25 (Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems) for 1 of 1 system. This deficiency could affect any patients that uses the ER or stays overnight in the facility.

Note: NFPA 25, 1998 Edition:
NFPA 25, Chapter 2, " General " 2-1 This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.

Findings:

During review of the sprinkler system documentation on July 9, 2012 between 11:00 a.m. and 11:30 a.m. it was observed that facility failed to have all devices on the sprinkler system routinely inspected or tested at the proper intervals or failed to document such actions. Currently the facility does not have all documentations of the routine inspection report being done.

Based on review of documentation the facility failed to provide routine inspection, testing and maintenance of the sprinkler system as per NFPA 25 (Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems) for 1 of 1 system. This deficiency could affect any patients that uses the ER or stays overnight in the facility.

Note: NFPA 25, 1998 Edition:
NFPA 25, Chapter 2, " General " 2-1 This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.

Findings:

During review of the sprinkler system documentation on July 9, 2012 between 2:00 p.m. and 2:30 p.m. it was observed that facility failed to have all devices on the sprinkler system routinely inspected or tested at the proper intervals or failed to document such actions. Currently the facility does not documentations of the routine inspection report being done within the last six months.

Based on observation the facility failed to have all the required kitchen suppression system and cooking equipment in accordance with NFPA 96 (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations) and NFPA 101 (Life Safety Code) for 1 of 1 system. This deficiency could affect any patient in the facility.

Note: NFPA 96, 1998 edition:
NFPA 96:7-10.1 Portable fire extinguishers shall be installed in kitchen cooking areas in accordance with NFPA 10, Standard for Portable Fire Extinguishers. Manufacturer ' s recommendations shall be followed.
and
NFPA 96:9-1.2.1 All listed appliances shall be installed in accordance with the terms of their listings and the manufacturer ' s instructions.

Findings:

An observation of the kitchen hood, suppression system, and equipment revealed the following deficiencies.

1. The K type fire extinguisher in the kitchen is past due for its annual inspection.
2. The left back burner on the stove is not staying lit. This could cause a buildup of gas in the kitchen area if not monitored.

Based on observation, the facility failed to exercise the generator under load each month for 1 of 1 generator as per NFPA 99:3-4.4.1.1 and NFPA 110. This deficiency affects all patients in the facility.

Note: NFPA 110:6-4.1 Level 1 and Level 2 EPSSs, including all components, shall be inspected weekly and shall be exercised at least once monthly under load, for a minimum of 30 minutes of not less than 30 percent of the EPS nameplate rating.

Findings:

Review of the generator log on July 9, 2012 between 2:00 p.m. and 2:30 p.m. revealed that there was no documentation of a load test been done or the generator was not being exercised each month for at least 30 minutes under load. The facility was only able to provide documentation of the weekly test for the last 4 months. Interview with the facility maintenance director during the survey process and at the exit interview verified that no additional documentation of the load testing was available.

Based on observations the facility failed to provide smoke barriers that were constructed with at least a one hour fire resistance rating for 2 of 3 walls as per National Fire Protection Association (NFPA) 101 (Life Safety Code). This deficiency affects 3 of 4 smoke compartments and any patient that comes in to the ER or stays overnight in the facility.

Note: NFPA 101, 2000 edition:
NFPA 101: 18.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.

Findings:

During facility tour on July 9, 2012 between 9:00 a.m. and 12:00 p.m., the integrity of the smoke barrier wall was observed to be compromised in the following areas.

1. There was a three inch conduit with a bundle of wires in it that is penetrating the smoke barrier wall between room 301 and the outpatient Pharmacy that is not sealed.
2. There was a one inch conduit that is penetrating the smoke barrier wall between room 301 and the outpatient Pharmacy that is not sealed.
3. Above the cross corridor doors between room 301 & the outpatient Pharmacy a piece of drywall around the roof joist is coming off and leaving a gap in the wall.
4. There is a gap between the drywall and the roof joist at the 400 hall smoke barrier that is not sealed.

Based on observation the facility failed to provide door to smoke barriers that close fully in accordance with National Fire Protection Association (NFPA) 101 (Life Safety Code). This deficiency affects 3 of 3 smoke barriers, 4of 4 smoke compartments and any patient that use the ER or stays overnight in the facility.

Note: NFPA 101, 2000 edition:
NFPA 101:18.2.2.2.6 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.

Findings:

During a tour of the facility on July 9, 2012 between 9:00 a.m. and12:00 p.m. it was observed that the following doors were not closing completely or resisting the passage of smoke. When the fire alarm system was activated the magnetic holding device did release the doors, but the doors did not close fully in the following areas.

1. The doors to the smoke barrier between the outpatient Pharmacy and room 301 are dragging on the frame preventing the doors from closing completely.
2. The door frame of the smoke barrier between the outpatient Pharmacy and room 301 has a 1 ½ inch by 1 ½ inch hole at the edge of the door jamb where the doors meet that is not sealed.
3. All three set of smoke barriers doors have a gap between the doors that would not resist the passage of smoke.

Based on observation and review of documentation, the facility failed to have the fire alarm system fully operational as per National Fire Protection Association (NFPA) 72 (National Fire Alarm Code) and NFPA 101 (Life Safety Code) for 1 of 1 system. This deficiency affects any patient that uses the ER or stays overnight in the facility.

Note: NFPA 101, 2000 edition:
NFPA 101: 9.6.1.4
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

Findings:

An observation was made on July 9, 2012 at 9:30 a.m. of the fire alarm system. Review of the annual inspection report (dated 4-12-12) revealed that the smoke detector in the staff lounge is not working properly and that three of the roof top A/C units do not have duct detectors in them.

Based on review of documentation the facility failed to provide routine inspection, testing and maintenance of the sprinkler system as per NFPA 25 (Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems) for 1 of 1 system. This deficiency could affect any patients that uses the ER or stays overnight in the facility.

Note: NFPA 25, 1998 Edition:
NFPA 25, Chapter 2, " General " 2-1 This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.

Findings:

During review of the sprinkler system documentation on July 9, 2012 between 11:00 a.m. and 11:30 a.m. it was observed that facility failed to have all devices on the sprinkler system routinely inspected or tested at the proper intervals or failed to document such actions. Currently the facility does not have all documentations of the routine inspection report being done.

Based on review of documentation the facility failed to provide routine inspection, testing and maintenance of the sprinkler system as per NFPA 25 (Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems) for 1 of 1 system. This deficiency could affect any patients that uses the ER or stays overnight in the facility.

Note: NFPA 25, 1998 Edition:
NFPA 25, Chapter 2, " General " 2-1 This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.

Findings:

During review of the sprinkler system documentation on July 9, 2012 between 2:00 p.m. and 2:30 p.m. it was observed that facility failed to have all devices on the sprinkler system routinely inspected or tested at the proper intervals or failed to document such actions. Currently the facility does not documentations of the routine inspection report being done within the last six months.

Based on observation the facility failed to have all the required kitchen suppression system and cooking equipment in accordance with NFPA 96 (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations) and NFPA 101 (Life Safety Code) for 1 of 1 system. This deficiency could affect any patient in the facility.

Note: NFPA 96, 1998 edition:
NFPA 96:7-10.1 Portable fire extinguishers shall be installed in kitchen cooking areas in accordance with NFPA 10, Standard for Portable Fire Extinguishers. Manufacturer ' s recommendations shall be followed.
and
NFPA 96:9-1.2.1 All listed appliances shall be installed in accordance with the terms of their listings and the manufacturer ' s instructions.

Findings:

An observation of the kitchen hood, suppression system, and equipment revealed the following deficiencies.

1. The K type fire extinguisher in the kitchen is past due for its annual inspection.
2. The left back burner on the stove is not staying lit. This could cause a buildup of gas in the kitchen area if not monitored.

Based on observation, the facility failed to exercise the generator under load each month for 1 of 1 generator as per NFPA 99:3-4.4.1.1 and NFPA 110. This deficiency affects all patients in the facility.

Note: NFPA 110:6-4.1 Level 1 and Level 2 EPSSs, including all components, shall be inspected weekly and shall be exercised at least once monthly under load, for a minimum of 30 minutes of not less than 30 percent of the EPS nameplate rating.

Findings:

Review of the generator log on July 9, 2012 between 2:00 p.m. and 2:30 p.m. revealed that there was no documentation of a load test been done or the generator was not being exercised each month for at least 30 minutes under load. The facility was only able to provide documentation of the weekly test for the last 4 months. Interview with the facility maintenance director during the survey process and at the exit interview verified that no additional documentation of the load testing was available.