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The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following was observed:

1. The door failed to latch - Recovery Room in Surgery.

2. The door failed to latch - Radiology/X-Ray.

3. The door failed to latch and close tight so as to resist passage of smoke - Patient Room 216.


NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.

The facility failed to maintain exit signs. Findings include: During the survey, the Exit Sign was observed not to be illuminated at exit from Surgery corridor.


LSC 101 2000 Edition, 7.10.5.2* Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of section 7.8

The facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following was observed:

1 . Unsealed penetrations around a group of wiring two seperate locations in the Smoke Barrier by Out Patient Registration.

2 . Unsealed penetrations around a group of wiring in the Smoke Barrier by Mechanical Room # 4.

3. Unsealed penetrations around a group of wiring in the Smoke Barrier by Patient Room 215.


NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

The facility failed to provide (maintain) separation of hazardous areas. Findings include: During the survey, the following was observed:


1. The Storage Room door failed to latch, Employee Lounge located in the Surgery Wing.

2. The Dietary Combustible Storage Room, over 50 sq. feet, door was not provided with a self-closing device.

3. Unsealed penetrations at the end of (2) sleeve's and around a section of conduit in the wall of Mechanical Room #4.

4. A 2' x 2' opening in the wall of a Combustible Storage Room, across from Mechanical Room #4.

NFPA 101, 19.3.2.1 and 8.4.1 Hazardous areas to be provided with smoke-resisting partitions and doors when protection consists of an automatic extinguishing system. Doors shall be self-closing with positive latching hardware.

The facility failed to provide a reliable means of egress to the public way. Observation during the survey included the following findings:

1. The Exit from the Surgery Wing failed to provide an all surface to the public way.

2. The Exit by Patient Room 220 failed to provide an all weather surface to the public way.

NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, single bulbed light fixture was observed at the Exit Discharge for the following Exits:

1. The Exit from the Surgery Wing.

2. The Exit by Patient Room 227.

3. The Exit by Patient Room 220.

4. The Exit Discharge Light is controled by a switch in the corridor by the Vending Machine Room.

NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.

The facility failed to conduct fire drills quarterly per shift, as observed during the survey. Findings include:

According to administrative staff, the nursing staff has three work shifts (6:00 am - 2:00 pm,
2:00 - 10:00 pm, 10:00 pm - 6:00 am), and dietary staff has two work shifts (5:00 am - 1:00 pm,
12:00 pm - 6:00 pm). According to documentation available during the survey, fire drills were conducted during the past 12 months as follows:

6/15/10 at 8:15 am
2/15/10 at 3:00 pm (sign in sheet only) and 9:10 (no sign in sheet)
12/3/09 at 10:22 am
9/23/09 at 8:05 pm

The facility failed to maintain a fire alarm system with approved component devices or equipment installed to provide effective warning of fire in any part of the building.
Findings include: During the survey, while testing the Fire Alarm System, upon activation of devices, the remote annunciator failed to indicate which device, or location of device, the Main Fire Panel indicated proper visual for each device, it was not located in a constanly attended area.


NFPA 101, 9.6.7, and 1999 NFPA 72, 1-5.7.1.2 Fire alarm systems serving two or more zones shall identify the zone of origin of the alarm initiation by annunciation or coded signal.

Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following was observed:

1. Corrosion build up on a sprinkler located in the Kitchen Janitor Closet.

1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.


2. Loose escutcheon plate on a sprinkler in the freezer and cooler.

3. Missing escutcheon plates throughout the facility.

2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

During the survey, documentation and interviews indicated the facility did not meet the minimum required frequencies for inspection, testing, and maintenance of the sprinkler system. Findings include:

Documentation was not available for the 5 year testing of the gauges.

NFPA 25, 9-2.8.2 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

During survey, the provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff.
This side of the inspection card was blank.


NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or owner's manual. As a minimum, this "quick check" or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

During the survey, documentation was not provided for the draperies/cubicle curtains to indicate if the standards for NFPA 701 flame resistant were met.

LSC 101,2000 10.3.1 Where required by the applicable provisions of this code, draperies, curtains, and other similar loosely hanging furnishings, and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

1. During the survey, based on observation and interview with the Maintenance staff, the OR Rooms were provided with a smoke vent system. The maintenance staff was not able to demonstrate the smoke venting system for this surveyor. The facility will have to determine if the system is provided and if so, documentation to indicate proper operation of system.

1976 and 1999, NFPA 99, 5-4.1 Supply and exhaust systems for windowless
anesthetizing locations shall be arranged to automatically vent smoke and products of combustion, and prevent recirculation of smoke originating within the surgical suite, and also prevent circulation of smoke entering the system intake, without interfering with the system exhaust function.


2. The battery-powered light in OR Room (1) was observed to be inoperable, during the survey.

Battery-Powered Emergency Lighting Units. One or more battery-powered emergency
lighting units shall be provided in accordance with NFPA 70, National Electrical Code,
Section 700-12(e).


1999 NFPA 70, 700-12. General Requirements (e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following: 1. A rechargeable battery; 2. A battery charging means; 3. Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and 4. A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment
The batteries shall be of suitable rating and capacity to supply and maintain at not less than 87? percent of the nominal battery voltage for the total lamp load associated with the unit for a period of at least 1? hours, or the unit equipment shall supply and maintain not less than 60 percent of the initial emergency illumination for a period of at least 1? hours. Storage batteries, whether of the acid or alkali type, shall be designed and constructed to meet the requirements of emergency service
Unit equipment shall be permanently fixed in place (i.e., not portable) and shall have all wiring to each unit installed in accordance with the requirements of any of the wiring methods in Chapter 3. Flexible cord and plug connection shall be permitted, provided that the cord does not exceed 3 ft (914 mm) in length. The branch circuit feeding the unit equipment shall be the same branch circuit as that serving the normal lighting in the area and connected ahead of any local switches. The branch circuit that feeds unit equipment shall be clearly identified at the distribution panel. Emergency illumination fixtures that obtain power from a unit equipment and are not part of the unit equipment shall be wired to the unit equipment as required by Section 700-9 and by one of the wiring methods of Chapter 3.
Exception: In a separate and uninterrupted area, supplied by a minimum of three normal lighting circuits, a separate branch circuit for unit equipment shall be permitted if it originates from the same panelboard as that of the normal lighting circuits and is provided with a lock-on feature.

During the survey, the Remote Annunciator for the generator was observed to be located in the Director Of Nursing Office. Panel was not operational, as this office is not a constantly attended location in the facility.

NFPA 99, 3-4.1.1.15 + Alarm Annunciator. A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows: (a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load, 2. When the battery charger is malfunctioning (b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following: 1. Low lubricating oil pressure, 2. Low water temperature (below those required in 3-4.1.1.9), 3. Excessive water temperature, 4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply, 5. Overcrank (failed to start), 6. Overspeed. Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

A) The facility utilized extension cords without overcurrent protection. Findings include: During the survey, the following was observed:

1. Two light fixtures in Mechanical Room #2 used extension cords to reach the electrical outlet.

2. Two light fixtures in Mechanical Room #4 used extension cords to reach the electrical outlet.

3. One light fixture in Mechanical Room #3 used extension cords to reach the electrical outlet.

1999 NFA 70, Article 240-4, and HFCA Transmittal Notice 22-99 prohibit the use of extension cords without overcurrent protection.


B) The facility failed to provide receptacles for appliances. Findings include: During the survey, a refrigerator was observed to be plugged into an extension cord in the X-Ray Server Room.

Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice
22-99.

The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following was observed:

1. The door failed to latch - Recovery Room in Surgery.

2. The door failed to latch - Radiology/X-Ray.

3. The door failed to latch and close tight so as to resist passage of smoke - Patient Room 216.


NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.

The facility failed to maintain exit signs. Findings include: During the survey, the Exit Sign was observed not to be illuminated at exit from Surgery corridor.


LSC 101 2000 Edition, 7.10.5.2* Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of section 7.8

The facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating. Findings include: During the survey, the following was observed:

1 . Unsealed penetrations around a group of wiring two seperate locations in the Smoke Barrier by Out Patient Registration.

2 . Unsealed penetrations around a group of wiring in the Smoke Barrier by Mechanical Room # 4.

3. Unsealed penetrations around a group of wiring in the Smoke Barrier by Patient Room 215.


NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

The facility failed to provide (maintain) separation of hazardous areas. Findings include: During the survey, the following was observed:


1. The Storage Room door failed to latch, Employee Lounge located in the Surgery Wing.

2. The Dietary Combustible Storage Room, over 50 sq. feet, door was not provided with a self-closing device.

3. Unsealed penetrations at the end of (2) sleeve's and around a section of conduit in the wall of Mechanical Room #4.

4. A 2' x 2' opening in the wall of a Combustible Storage Room, across from Mechanical Room #4.

NFPA 101, 19.3.2.1 and 8.4.1 Hazardous areas to be provided with smoke-resisting partitions and doors when protection consists of an automatic extinguishing system. Doors shall be self-closing with positive latching hardware.

The facility failed to provide a reliable means of egress to the public way. Observation during the survey included the following findings:

1. The Exit from the Surgery Wing failed to provide an all surface to the public way.

2. The Exit by Patient Room 220 failed to provide an all weather surface to the public way.

NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, single bulbed light fixture was observed at the Exit Discharge for the following Exits:

1. The Exit from the Surgery Wing.

2. The Exit by Patient Room 227.

3. The Exit by Patient Room 220.

4. The Exit Discharge Light is controled by a switch in the corridor by the Vending Machine Room.

NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.

The facility failed to conduct fire drills quarterly per shift, as observed during the survey. Findings include:

According to administrative staff, the nursing staff has three work shifts (6:00 am - 2:00 pm,
2:00 - 10:00 pm, 10:00 pm - 6:00 am), and dietary staff has two work shifts (5:00 am - 1:00 pm,
12:00 pm - 6:00 pm). According to documentation available during the survey, fire drills were conducted during the past 12 months as follows:

6/15/10 at 8:15 am
2/15/10 at 3:00 pm (sign in sheet only) and 9:10 (no sign in sheet)
12/3/09 at 10:22 am
9/23/09 at 8:05 pm

The facility failed to maintain a fire alarm system with approved component devices or equipment installed to provide effective warning of fire in any part of the building.
Findings include: During the survey, while testing the Fire Alarm System, upon activation of devices, the remote annunciator failed to indicate which device, or location of device, the Main Fire Panel indicated proper visual for each device, it was not located in a constanly attended area.


NFPA 101, 9.6.7, and 1999 NFPA 72, 1-5.7.1.2 Fire alarm systems serving two or more zones shall identify the zone of origin of the alarm initiation by annunciation or coded signal.

Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following was observed:

1. Corrosion build up on a sprinkler located in the Kitchen Janitor Closet.

1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.


2. Loose escutcheon plate on a sprinkler in the freezer and cooler.

3. Missing escutcheon plates throughout the facility.

2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

During the survey, documentation and interviews indicated the facility did not meet the minimum required frequencies for inspection, testing, and maintenance of the sprinkler system. Findings include:

Documentation was not available for the 5 year testing of the gauges.

NFPA 25, 9-2.8.2 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

During survey, the provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff.
This side of the inspection card was blank.


NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or owner's manual. As a minimum, this "quick check" or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

During the survey, documentation was not provided for the draperies/cubicle curtains to indicate if the standards for NFPA 701 flame resistant were met.

LSC 101,2000 10.3.1 Where required by the applicable provisions of this code, draperies, curtains, and other similar loosely hanging furnishings, and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

1. During the survey, based on observation and interview with the Maintenance staff, the OR Rooms were provided with a smoke vent system. The maintenance staff was not able to demonstrate the smoke venting system for this surveyor. The facility will have to determine if the system is provided and if so, documentation to indicate proper operation of system.

1976 and 1999, NFPA 99, 5-4.1 Supply and exhaust systems for windowless
anesthetizing locations shall be arranged to automatically vent smoke and products of combustion, and prevent recirculation of smoke originating within the surgical suite, and also prevent circulation of smoke entering the system intake, without interfering with the system exhaust function.


2. The battery-powered light in OR Room (1) was observed to be inoperable, during the survey.

Battery-Powered Emergency Lighting Units. One or more battery-powered emergency
lighting units shall be provided in accordance with NFPA 70, National Electrical Code,
Section 700-12(e).


1999 NFPA 70, 700-12. General Requirements (e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following: 1. A rechargeable battery; 2. A battery charging means; 3. Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and 4. A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment
The batteries shall be of suitable rating and capacity to supply and maintain at not less than 87? percent of the nominal battery voltage for the total lamp load associated with the unit for a period of at least 1? hours, or the unit equipment shall supply and maintain not less than 60 percent of the initial emergency illumination for a period of at least 1? hours. Storage batteries, whether of the acid or alkali type, shall be designed and constructed to meet the requirements of emergency service
Unit equipment shall be permanently fixed in place (i.e., not portable) and shall have all wiring to each unit installed in accordance with the requirements of any of the wiring methods in Chapter 3. Flexible cord and plug connection shall be permitted, provided that the cord does not exceed 3 ft (914 mm) in length. The branch circuit feeding the unit equipment shall be the same branch circuit as that serving the normal lighting in the area and connected ahead of any local switches. The branch circuit that feeds unit equipment shall be clearly identified at the distribution panel. Emergency illumination fixtures that obtain power from a unit equipment and are not part of the unit equipment shall be wired to the unit equipment as required by Section 700-9 and by one of the wiring methods of Chapter 3.
Exception: In a separate and uninterrupted area, supplied by a minimum of three normal lighting circuits, a separate branch circuit for unit equipment shall be permitted if it originates from the same panelboard as that of the normal lighting circuits and is provided with a lock-on feature.

During the survey, the Remote Annunciator for the generator was observed to be located in the Director Of Nursing Office. Panel was not operational, as this office is not a constantly attended location in the facility.

NFPA 99, 3-4.1.1.15 + Alarm Annunciator. A remote annunciator, storage battery powered, shall be provided to operate outside of the Generating Room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows: (a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load, 2. When the battery charger is malfunctioning (b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following: 1. Low lubricating oil pressure, 2. Low water temperature (below those required in 3-4.1.1.9), 3. Excessive water temperature, 4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply, 5. Overcrank (failed to start), 6. Overspeed. Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

A) The facility utilized extension cords without overcurrent protection. Findings include: During the survey, the following was observed:

1. Two light fixtures in Mechanical Room #2 used extension cords to reach the electrical outlet.

2. Two light fixtures in Mechanical Room #4 used extension cords to reach the electrical outlet.

3. One light fixture in Mechanical Room #3 used extension cords to reach the electrical outlet.

1999 NFA 70, Article 240-4, and HFCA Transmittal Notice 22-99 prohibit the use of extension cords without overcurrent protection.


B) The facility failed to provide receptacles for appliances. Findings include: During the survey, a refrigerator was observed to be plugged into an extension cord in the X-Ray Server Room.

Appliances, such as air conditioners and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice
22-99.