HospitalInspections.org

Based on observation and interview, the facility did not provide a common separation wall with rated wall construction. This deficient practice could affect all patients, staff, and visitors in 8 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 10, 2013 at 8:30 am, observation revealed on the 1st floor in the passage into the surgery area from the main hospital corridor, that the 2 hour separation wall and rated doors were not present at this location. In addition, all doors into the surgery building are not 1-1/2 hour rated doors. The surgery addition, built in 1993, is a Type II (0,0,0) building and is separated from the Type II(1,1,1) building. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation and interview, the facility did not provide and maintain the required building construction type with a compliant type of construction and sealed floor penetrations. This deficient practice could affect all patients, staff, and visitors in 8 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 10, 2013 at 8:00 am, observation revealed that the building's construction type was not compliant because the lower level is not a basement because more than 50% of the level is exposed for the building perimeter. Therefore the building is a three (3) story building. The facility produced a life safety plan indicating that the building is a Type II (1,1,1) construction type building. A Type II (1,1,1) three story building is permitted only if the building is fully sprinkled. The build is not fully sprinklered protected. This observed situation was not compliant with NFPA 101 (2000 ed.), Table 19.1.6.2.

2. On July 10, 2013 at 9:25 am, observation revealed on the lower level in the rest room by maintenance shop, that there were penetration(s) through the ceiling that were not fire stopped according to an approved method. The deficiency included a polyvinyl chloride (PVC) pipe that did not have a fire collar or fire caulk. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6 and 8.2.3.2.4.2.

These conditions werre confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation and interview, the facility did not provide room finishes with rated wall finishes. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 9, 2013 at 8:55 am, observation revealed on the 2nd floor in the clinic check-in room, that there was a peg board mounted on the wall as a secondary finish and the facility could not confirm the peg board had the appropriate finish rating. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.3.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation and interview, the facility did not provide corridor separation doors with positive-latching hardware. This deficient practice could affect all patients, staff, and visitors in 3 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 9, 2013 at 9:00 am, observation revealed on the 2nd floor in the clinic waiting area, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

2. On July 9, 2013 at 10:10 am, observation revealed on the 1st floor in the old tub room, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

3. On July 9, 2013 at 10:35 am, observation revealed on the 1st floor in the Solarium, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations. This deficient practice could affect all patients, staff, and visitors in 2 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 10, 2013 at 1:00 pm, observation revealed on the lower level floor in the corridor above the across corridor doors by the conference room, that conduit penetration(s) were not sealed according to an approved method. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation and interview, the facility did not enclose hazardous rooms with rated doors. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 9, 2013 at 10:30 am, observation revealed on the 1st floor in Rooms 125, 149, 153, 155, 157, and 158 that the fire barrier door could not be verified to have the required rating. In addition, there was no closer on the door and the walls could not be verified as having a 1 hour fire rating. Storage has been added to these former patient rooms in quantities deemed hazardous. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation and interview, the facility did provide stairways that did open to unoccupied rooms. This deficient practice could affect all patients, staff, and visitors in 5 of the 8 smoke compartments.

FINDINGS INCLUDE:

1) On 07/09/2013 at 11 am, observation revealed that the storage / air handle room in the lower lever, which is an unoccupied room, opens into an exit stairway. This observed situation was not compliant with NFPA 101, (2000 edition) 7.1.3.2.1.

2) On 07/09/2013 at 8:50 am observation revealed that the stairs to the penthouse, which is an unoccupied room, opens onto the exit stairway. This observed situation was not compliant with NFPA 101, (2000 edition) 7.1.3.2.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).

Based upon observation and interview, the facility failed to provide exit access that is arranged so that exits are readily accessible at all times. This deficient practice could affect all patients, staff, and visitors in 4 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 8, 2013 at 3:00 PM, observation revealed on the 2nd floor in the St. Joe Gym, in the 'back room' if the draw curtains are closed, that the egress path was not compliant. A door that swings is required in the path of egress. The egress out was prevented from swinging by heavy furniture. The draw curtain had a stop to prevent the curtain from operating. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.7,

2. On July 10, 2013 at 8:57 am, observation revealed on the lower level floor in the rehab tub room, that the exit path was not readily accessible because there was a pulley on the door that restricted the door width when an occupant attempted to egress out of the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.5.1.1.

3. On July 9, 2013 at 8:45 am, observation revealed on the 2nd floor in the corridor that items were stored in the egress pathway, including 4 signs, 2 by the clinic check-in point and 2 at the east end of the corridor. The items were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use and relocation during a fire emergency. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.1 and 7.1.10.1.

4. On July 9, 2013 at 8:35 am, observation revealed on the 2nd floor in the corridor by the clinic check-in point, that the door release hardware required more than a single motion to release the door for exiting. The hardware included locking and a separate latching hardware set. A keyed dead-bolt on the corridor side was still operational. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.5.4.

5. On 07/10/2013 at 11:05 am, observation revealed that the across corridor door to the OR from the ER was locked. This created a dead end corridor greater than 30 feet.

These deficiencies were confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 9, 2013 at 1:30 PM, observation revealed on the 1st floor in the Lab Waiting area, which is a room open to the corridor, that the clear and unobstructed width of the corridor was reduced by furniture to less than the width of the corridor leading into and out of the 'room' of a nominal 6 foot width. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.3.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 with a smoke detector at the main fire panel. This deficient practice could affect all patients, staff, and visitors in 8 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 10, 2013 at 9:35 am, observation revealed on the lower level floor in the boiler room, that the main fire alarm panel was in an area that was not continuously occupied and a smoke detector was not provided. This observed situation was not compliant with NFPA 72 (1999 ed.), 1-5.6. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with sprinklers free of obstructions near the ceiling, all rooms sprinkled when the code required full sprinkler protection, and unobstructed water distribution. This deficient practice could affect all patients, staff, and visitors in 3 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 9, 2013 at 2:54 PM, observation revealed on the 1st floor in the Middle office, of Print Patient Accounts, that items were placed near the ceiling within 18" of the sprinkler deflector. These items obstructed the discharge of sprinkler water from reaching the intended coverage for the room or space. The obstruction included 3 double cabinet files which were 6 and 8 inches from the bottom of the sprinkler deflector. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

2. On July 9, 2013 at 11:45 am, observation revealed on the 1st floor in the restroom shower, across from Room 109, that there was no sprinkler or approved alternative suppression system provided within this space. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.5.1.

3. On July 9, 2013 at 10:45 am, observation revealed on the 1st floor in the Ultrasound room, Room 119, that the discharge of sprinkler water was prevented from reaching the intended coverage for the room or space. The obstruction included a wall mounted TV near an adjacent side wall sprinkler head.

4. On July 9, 2013 at 10:50 am, observation revealed on the 1st floor in Rooms 118 and 119, that no sprinkler coverage was provided within these shower or toilet rooms. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

5. On July 9, 2013 at 11:23 am, observation revealed on the 1st floor in the X Ray room, that the discharge of sprinkler water was prevented from reaching the intended coverage for the room or space. The obstruction included the x-ray machine that was not in the 'home position'. The x-ray machine was within 1 foot of the sprinkler and was blocking the sprinkler discharge pattern to the west. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation and interview, the facility did not provide supervision of the control valves of the sprinkler system. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 10, 2013 at 9:50 am, observation revealed on the lower level floor in the boiler room, that the sprinkler control valve was not supervised by the fire alarm system. The dry system was locked with a chain. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.7.2.1 and NFPA 72.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have intact escutcheon rings. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 9, 2013 at 8:25 am, observation revealed on the 2nd floor in the staff bathroom, Room 305, that the escutcheon ring on the sprinkler was too small for the hole in the ceiling. This gap may reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with neutral airflow between the corridor and rooms, and ventilation systems that comply with NFPA 90A. This deficient practice could affect all patients, staff, and visitors in 3 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On 07-10-2013 at 11:10 am, observation revealed on the patient floors, that airflow between the corridor and the room was not neutral. Some rooms are using the corridor as a supply air plenum and other rooms are using the corridor as a return air plenum. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1 9.2 and NFPA 90A, 2-3.11.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).

Based on observation and interview, the facility did not maintain an egress path that was free of highly flammable furnishings/decoration and non-combustible decorations. This deficient practice could affect all patients, staff, and visitors in 2 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 9, 2013 at 9:30 am, observation revealed on the 2nd floor in the Rooms 220 and 225, that decorations made with combustible materials were used. The items could not be confirmed as being flame-retardant. The decorations included paper and quilts on the wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.2 thru 19.7.5.4.

2. On July 9, 2013 at 1:00 pm, observation revealed on the 1st floor in the Pharmacy, that decorations made with combustible materials were used. The items could not be confirmed as being flame-retardant. The decorations included the pull curtains in the pharmacy. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.2 thru 19.7.5.4.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation and interview, the facility did not provide properly sized linen/trash collection receptacles when located outside of a hazardous room. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 10, 2013 at 10:30 am, observation revealed on the lower level floor in the medical records, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. A unattended 92 gallon trash container was located in a non-fire rated room. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Item #1
NFPA 110 Standard for Emergency and Standby Power Systems (1985 edition (the generator was install under))

5-2.1 "For Level 1 installations, energy converters shall be located in separate service room dedicated to the EPS, separated from the remainder of the building by fire separations having a minimum two-hour fire rating, or shall be located in an adequate enclosure outside the building capable of preventing the entrance of snow or rain. Rooms for Level 1 shall not be shared with other equipment or electrical service equipment not a part of the EPSS."

Based on observation and interview, the facility failed to properly isolate the emergency generator (EPS) in its own rated room. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On 07/10/2013 at 7:30 am, observation revealed that the emergency generator room shared a common room with a refrigeration system. The generator is required to be located in a room without other mechanical systems. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).

Item # 2

NFPA 101 LIFE SAFETY CODE STANDARD

7.1.5 Headroom Means of egress shall be designed and maintained to provide headroom as provided in their sections of this Code and shall be not less than 7 feet 6 inches with projections from the ceiling not less than 6 feet 8 inches nominal height above the finished floor.

Based on observation and interview, the facility failed to properly maintain the proper head room in the means of egress. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On 07/10/2013 at 7:50 am observation revealed that the ceiling height in the corridor from the ground floor west entrance is less than 7'-0". The 38 foot long corridor has a height of 86" (7'-2") at one end and slopes to 80" (6'-8") at the other. This observed situation was not compliant with NFPA 101 (2000 edition) section 7.1.3.2.1(d). This deficiency was confirmed at the time of discovery in an interview with staff K (Director of Facilities).

Based on observation and interview, the facility did not provide space for oxygen storage with separation of oxygen from combustibles. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 9, 2013 at 8:15 am, observation revealed on the 2nd floor in the Ambulatory Supply room, that combustible materials were stored too close to the storage site of oxygen cylinders. The oxygen tank was right next to a shelf containing plastic combustibles. This observed situation was not compliant with NFPA 99 (1999 ed.), 4-3.1.1.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation and interview the facility did not monitor derangement signals at a continuously monitored location and did not provide a remote stop switch for the generator. This deficient practice could affect all patients, staff, and visitors in 8 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On 07/08/2013 at 3:50 pm observation revealed on the lower level floor in the maintenance shop, that audible and visual derangement signals were not located in a continuously monitored location. A generator annunciation panel was located in the main entrance (ER area). The observed situation was not compliant with NFPA 110 (1999 edition), 3-5.5.2(d) & NFPA 99 (1999 edition), 3-4.1.1.15(b).

2. On 07/08/2013 at 4:00 pm, observation revealed on the outside floor in the generator room, that the emergency generator was not provided with a remote stop switch. The stop shall be located outside of the generator room. This observed situation was not compliant with NFPA 110 (1999 ed.), 3-5.5.6.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).

Based on observation and interview, the facility did not provide a Type I essential electrical system that was properly divided. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On 07/10/2013 at 11:15 am observation revealed that the Type 1 emergency electrical system did not have normal power outlets in the recovery and OR areas. Both critical outlet and normal outlets are required or the critical care outlets are permitted if they are on two different transfer switches. This observed situation was not compliant with NFPA 99 (1999 edition) 3-4.2.2.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with protection of electrical equipment from physical damage, and fixed wiring rather than extension cords. This deficient practice could affect all patients, staff, and visitors in 2 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 9, 2013 at 9:15 am, observation revealed on the 2nd floor in the clinic check-out room, that the electrical equipment did not have an appropriate guard to prevent damage from likely exposure to physical damage. A blue extension cord was taped to the wall and desk and was plugged into a strip power cord. Various lights and appliances were plugged into these cords. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-27(b).

2. On July 10, 2013 at 9:45 am, observation revealed on the lower level floor in the boiler room, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a grinder and saw. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation and interview, the facility did not provide a common separation wall with rated wall construction. This deficient practice could affect all patients, staff, and visitors in 8 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 10, 2013 at 8:30 am, observation revealed on the 1st floor in the passage into the surgery area from the main hospital corridor, that the 2 hour separation wall and rated doors were not present at this location. In addition, all doors into the surgery building are not 1-1/2 hour rated doors. The surgery addition, built in 1993, is a Type II (0,0,0) building and is separated from the Type II(1,1,1) building. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.1.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
______________________________________

Based on observation and interview, the facility did not provide and maintain the required building construction type with a compliant type of construction and sealed floor penetrations. This deficient practice could affect all patients, staff, and visitors in 8 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 10, 2013 at 8:00 am, observation revealed that the building's construction type was not compliant because the lower level is not a basement because more than 50% of the level is exposed for the building perimeter. Therefore the building is a three (3) story building. The facility produced a life safety plan indicating that the building is a Type II (1,1,1) construction type building. A Type II (1,1,1) three story building is permitted only if the building is fully sprinkled. The build is not fully sprinklered protected. This observed situation was not compliant with NFPA 101 (2000 ed.), Table 19.1.6.2.

2. On July 10, 2013 at 9:25 am, observation revealed on the lower level in the rest room by maintenance shop, that there were penetration(s) through the ceiling that were not fire stopped according to an approved method. The deficiency included a polyvinyl chloride (PVC) pipe that did not have a fire collar or fire caulk. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6 and 8.2.3.2.4.2.

These conditions werre confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
______________________________________

Based on observation and interview, the facility did not provide room finishes with rated wall finishes. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 9, 2013 at 8:55 am, observation revealed on the 2nd floor in the clinic check-in room, that there was a peg board mounted on the wall as a secondary finish and the facility could not confirm the peg board had the appropriate finish rating. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.3.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
______________________________________

Based on observation and interview, the facility did not provide corridor separation doors with positive-latching hardware. This deficient practice could affect all patients, staff, and visitors in 3 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 9, 2013 at 9:00 am, observation revealed on the 2nd floor in the clinic waiting area, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

2. On July 9, 2013 at 10:10 am, observation revealed on the 1st floor in the old tub room, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

3. On July 9, 2013 at 10:35 am, observation revealed on the 1st floor in the Solarium, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
______________________________________

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations. This deficient practice could affect all patients, staff, and visitors in 2 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 10, 2013 at 1:00 pm, observation revealed on the lower level floor in the corridor above the across corridor doors by the conference room, that conduit penetration(s) were not sealed according to an approved method. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.7.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
______________________________________

Based on observation and interview, the facility did not enclose hazardous rooms with rated doors. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 9, 2013 at 10:30 am, observation revealed on the 1st floor in Rooms 125, 149, 153, 155, 157, and 158 that the fire barrier door could not be verified to have the required rating. In addition, there was no closer on the door and the walls could not be verified as having a 1 hour fire rating. Storage has been added to these former patient rooms in quantities deemed hazardous. The room was considered hazardous because it exceeded 100 sq ft and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), 18.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
______________________________________

Based on observation and interview, the facility did provide stairways that did open to unoccupied rooms. This deficient practice could affect all patients, staff, and visitors in 5 of the 8 smoke compartments.

FINDINGS INCLUDE:

1) On 07/09/2013 at 11 am, observation revealed that the storage / air handle room in the lower lever, which is an unoccupied room, opens into an exit stairway. This observed situation was not compliant with NFPA 101, (2000 edition) 7.1.3.2.1.

2) On 07/09/2013 at 8:50 am observation revealed that the stairs to the penthouse, which is an unoccupied room, opens onto the exit stairway. This observed situation was not compliant with NFPA 101, (2000 edition) 7.1.3.2.1.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).

Based upon observation and interview, the facility failed to provide exit access that is arranged so that exits are readily accessible at all times. This deficient practice could affect all patients, staff, and visitors in 4 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 8, 2013 at 3:00 PM, observation revealed on the 2nd floor in the St. Joe Gym, in the 'back room' if the draw curtains are closed, that the egress path was not compliant. A door that swings is required in the path of egress. The egress out was prevented from swinging by heavy furniture. The draw curtain had a stop to prevent the curtain from operating. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.7,

2. On July 10, 2013 at 8:57 am, observation revealed on the lower level floor in the rehab tub room, that the exit path was not readily accessible because there was a pulley on the door that restricted the door width when an occupant attempted to egress out of the room. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.5.1.1.

3. On July 9, 2013 at 8:45 am, observation revealed on the 2nd floor in the corridor that items were stored in the egress pathway, including 4 signs, 2 by the clinic check-in point and 2 at the east end of the corridor. The items were stored in this location for greater than 30 minutes and were not attended by a staff person that was responsible for their use and relocation during a fire emergency. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.1 and 7.1.10.1.

4. On July 9, 2013 at 8:35 am, observation revealed on the 2nd floor in the corridor by the clinic check-in point, that the door release hardware required more than a single motion to release the door for exiting. The hardware included locking and a separate latching hardware set. A keyed dead-bolt on the corridor side was still operational. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.2.1.5.4.

5. On 07/10/2013 at 11:05 am, observation revealed that the across corridor door to the OR from the ER was locked. This created a dead end corridor greater than 30 feet.

These deficiencies were confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).

Based on observation and interview, the facility did not provide and maintain corridors and aisles that were at least the minimal clear width required by the code. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 9, 2013 at 1:30 PM, observation revealed on the 1st floor in the Lab Waiting area, which is a room open to the corridor, that the clear and unobstructed width of the corridor was reduced by furniture to less than the width of the corridor leading into and out of the 'room' of a nominal 6 foot width. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.3.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
______________________________________

Based on observation and interview, the facility did not provide a fire alarm system that was installed according to NFPA 72 with a smoke detector at the main fire panel. This deficient practice could affect all patients, staff, and visitors in 8 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 10, 2013 at 9:35 am, observation revealed on the lower level floor in the boiler room, that the main fire alarm panel was in an area that was not continuously occupied and a smoke detector was not provided. This observed situation was not compliant with NFPA 72 (1999 ed.), 1-5.6. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with sprinklers free of obstructions near the ceiling, all rooms sprinkled when the code required full sprinkler protection, and unobstructed water distribution. This deficient practice could affect all patients, staff, and visitors in 3 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 9, 2013 at 2:54 PM, observation revealed on the 1st floor in the Middle office, of Print Patient Accounts, that items were placed near the ceiling within 18" of the sprinkler deflector. These items obstructed the discharge of sprinkler water from reaching the intended coverage for the room or space. The obstruction included 3 double cabinet files which were 6 and 8 inches from the bottom of the sprinkler deflector. This obstruction would interfere with the development of the water spray pattern and may reduce the amount of water that the code requires to reach all portions of the protected floor space. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

2. On July 9, 2013 at 11:45 am, observation revealed on the 1st floor in the restroom shower, across from Room 109, that there was no sprinkler or approved alternative suppression system provided within this space. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.5.1.

3. On July 9, 2013 at 10:45 am, observation revealed on the 1st floor in the Ultrasound room, Room 119, that the discharge of sprinkler water was prevented from reaching the intended coverage for the room or space. The obstruction included a wall mounted TV near an adjacent side wall sprinkler head.

4. On July 9, 2013 at 10:50 am, observation revealed on the 1st floor in Rooms 118 and 119, that no sprinkler coverage was provided within these shower or toilet rooms. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

5. On July 9, 2013 at 11:23 am, observation revealed on the 1st floor in the X Ray room, that the discharge of sprinkler water was prevented from reaching the intended coverage for the room or space. The obstruction included the x-ray machine that was not in the 'home position'. The x-ray machine was within 1 foot of the sprinkler and was blocking the sprinkler discharge pattern to the west. This observed situation was not compliant with NFPA 13 (1999 ed.), 5-6.5.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation and interview, the facility did not provide supervision of the control valves of the sprinkler system. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 10, 2013 at 9:50 am, observation revealed on the lower level floor in the boiler room, that the sprinkler control valve was not supervised by the fire alarm system. The dry system was locked with a chain. This observed situation was not compliant with NFPA 101 (2000 ed.), 9.7.2.1 and NFPA 72.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation, interview and a review of documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have intact escutcheon rings. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 9, 2013 at 8:25 am, observation revealed on the 2nd floor in the staff bathroom, Room 305, that the escutcheon ring on the sprinkler was too small for the hole in the ceiling. This gap may reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), 1-11.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with neutral airflow between the corridor and rooms, and ventilation systems that comply with NFPA 90A. This deficient practice could affect all patients, staff, and visitors in 3 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On 07-10-2013 at 11:10 am, observation revealed on the patient floors, that airflow between the corridor and the room was not neutral. Some rooms are using the corridor as a supply air plenum and other rooms are using the corridor as a return air plenum. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1 9.2 and NFPA 90A, 2-3.11.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).

Based on observation and interview, the facility did not maintain an egress path that was free of highly flammable furnishings/decoration and non-combustible decorations. This deficient practice could affect all patients, staff, and visitors in 2 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 9, 2013 at 9:30 am, observation revealed on the 2nd floor in the Rooms 220 and 225, that decorations made with combustible materials were used. The items could not be confirmed as being flame-retardant. The decorations included paper and quilts on the wall. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.2 thru 19.7.5.4.

2. On July 9, 2013 at 1:00 pm, observation revealed on the 1st floor in the Pharmacy, that decorations made with combustible materials were used. The items could not be confirmed as being flame-retardant. The decorations included the pull curtains in the pharmacy. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.2 thru 19.7.5.4.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation and interview, the facility did not provide properly sized linen/trash collection receptacles when located outside of a hazardous room. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 10, 2013 at 10:30 am, observation revealed on the lower level floor in the medical records, that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. A unattended 92 gallon trash container was located in a non-fire rated room. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Item #1
NFPA 110 Standard for Emergency and Standby Power Systems (1985 edition (the generator was install under))

5-2.1 "For Level 1 installations, energy converters shall be located in separate service room dedicated to the EPS, separated from the remainder of the building by fire separations having a minimum two-hour fire rating, or shall be located in an adequate enclosure outside the building capable of preventing the entrance of snow or rain. Rooms for Level 1 shall not be shared with other equipment or electrical service equipment not a part of the EPSS."

Based on observation and interview, the facility failed to properly isolate the emergency generator (EPS) in its own rated room. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On 07/10/2013 at 7:30 am, observation revealed that the emergency generator room shared a common room with a refrigeration system. The generator is required to be located in a room without other mechanical systems. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).

Item # 2

NFPA 101 LIFE SAFETY CODE STANDARD

7.1.5 Headroom Means of egress shall be designed and maintained to provide headroom as provided in their sections of this Code and shall be not less than 7 feet 6 inches with projections from the ceiling not less than 6 feet 8 inches nominal height above the finished floor.

Based on observation and interview, the facility failed to properly maintain the proper head room in the means of egress. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On 07/10/2013 at 7:50 am observation revealed that the ceiling height in the corridor from the ground floor west entrance is less than 7'-0". The 38 foot long corridor has a height of 86" (7'-2") at one end and slopes to 80" (6'-8") at the other. This observed situation was not compliant with NFPA 101 (2000 edition) section 7.1.3.2.1(d). This deficiency was confirmed at the time of discovery in an interview with staff K (Director of Facilities).

Based on observation and interview, the facility did not provide space for oxygen storage with separation of oxygen from combustibles. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 9, 2013 at 8:15 am, observation revealed on the 2nd floor in the Ambulatory Supply room, that combustible materials were stored too close to the storage site of oxygen cylinders. The oxygen tank was right next to a shelf containing plastic combustibles. This observed situation was not compliant with NFPA 99 (1999 ed.), 4-3.1.1.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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Based on observation and interview the facility did not monitor derangement signals at a continuously monitored location and did not provide a remote stop switch for the generator. This deficient practice could affect all patients, staff, and visitors in 8 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On 07/08/2013 at 3:50 pm observation revealed on the lower level floor in the maintenance shop, that audible and visual derangement signals were not located in a continuously monitored location. A generator annunciation panel was located in the main entrance (ER area). The observed situation was not compliant with NFPA 110 (1999 edition), 3-5.5.2(d) & NFPA 99 (1999 edition), 3-4.1.1.15(b).

2. On 07/08/2013 at 4:00 pm, observation revealed on the outside floor in the generator room, that the emergency generator was not provided with a remote stop switch. The stop shall be located outside of the generator room. This observed situation was not compliant with NFPA 110 (1999 ed.), 3-5.5.6.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).

Based on observation and interview, the facility did not provide a Type I essential electrical system that was properly divided. This deficient practice could affect all patients, staff, and visitors in 1 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On 07/10/2013 at 11:15 am observation revealed that the Type 1 emergency electrical system did not have normal power outlets in the recovery and OR areas. Both critical outlet and normal outlets are required or the critical care outlets are permitted if they are on two different transfer switches. This observed situation was not compliant with NFPA 99 (1999 edition) 3-4.2.2.2. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with protection of electrical equipment from physical damage, and fixed wiring rather than extension cords. This deficient practice could affect all patients, staff, and visitors in 2 of the 8 smoke compartments.

FINDINGS INCLUDE:

1. On July 9, 2013 at 9:15 am, observation revealed on the 2nd floor in the clinic check-out room, that the electrical equipment did not have an appropriate guard to prevent damage from likely exposure to physical damage. A blue extension cord was taped to the wall and desk and was plugged into a strip power cord. Various lights and appliances were plugged into these cords. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-27(b).

2. On July 10, 2013 at 9:45 am, observation revealed on the lower level floor in the boiler room, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to a grinder and saw. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff K (Director of Facilities).
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