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Based on observation and staff interview, the facility failed to ensure one smoke barrier door was resistant to the passage of smoke in 1 of 4 smoke compartments. The findings were:

Observation on 11/15/11 at 12:48 PM revealed the cross corridor smoke barrier double doors between the laundry and physical therapy were held open with maglocks. However, upon release, the doors were unable to close completely. The maintenance manager confirmed the finding at the time of the observation.

Reference: NFPA 101, Life Safety Code, 2000 edition
19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self closing or automatic closing in accordance with 19.2.2.2.6.
8.3.4.1 Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be withour undercuts, louvers, or grilles.

Based on observation and staff interview, the facility failed to ensure 6 of 14 emergency exit lights were properly illuminated. The findings were:

Observations on 11/15/11 between 11:45 AM and 2:48 PM revealed six emergency exit lights had one of two light bulbs burned out in the following locations:
a. Over the door between the kitchen and the staff dining room.
b. Over the door between the kitchen and the main hallway.
c. Over the main entrance into the reception area.
d. In the hallway by the administration office and cross corridor doors.
e. Over the door between the emergency room hallway and the ambulance area.
f. Over the door between the ambulance area and the ambulance garage.
Interview with the maintenance manager at the time of the observations confirmed the bulbs were burned out.

Reference: NFPA 101, Life Safety Code, 2000 edition.
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.
7.10.5.1 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 Setion 7.8.
7.8.1.4 Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less that 0.2 ft-candles.

Based on record review and staff interview the facility failed to ensure the fire suppression (sprinkler) system was properly maintained in 1 of 4 smoke compartments. The findings were:

Observations on 11/15/11 at 1:48 PM revealed a ceiling mounted sprinkler head was blocked by moping materials in the janitor's store room (mop/washer room). Interview with the maintenance manager at the above time confirmed the observation.

Ref: 2000 NFPA 101 Section 18.3.5.1; 9.7.1.1; NFPA 13, 1999 edition
5-5.6 Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 in or greater.

Based on observation and staff interview, the facility failed to inspect 4 of 25 portable fire extinguishers during the previous year in accordance with NFPA 10 Section 4-4.1. The findings were:

Observation of facility fire extinguishers on 11/15/11 between 11:45 AM and 2:48 PM revealed an inspection tag dated 2009 was attached to the fire extinguishers located in the lab, the maintenance room and the procedure room. In addition, an inspection tag dated 2008 was attached to the fire extinguisher in the central supply room. Interview with facility manager at the times listed above confirmed the extinguishers were improperly tagged.

NFPA 101, Life Safety Code, 2000 edition.
Sections 19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10.
4-4.1 Maintenance Frequency. Extinguishers shall be subjected to maintenance not more than one year apart or when specifically indicated by an inspection.

Based on observation and staff interview, the facility failed to ensure compliance with the National Electric Code in 2 of 4 smoke compartments. The findings were:

Observations on 11/15/11 between 11:45 AM and 2:48 PM revealed a surge protector was plugged into another surge protector in the emergency services office, in the nursing office, and in the medical records office. Plugged into the surge protectors were business machines, including computers, printers. In addition, a dimmer wall light switch was missing an electrical cover in the xray procedure room and the wall light switch in resident room #7 was cracked. Interview with the maintenance manager at the time of the observations confirmed the above findings.

Reference: NFPA 70, National Electrical Code, 1999 Edition.
Article 400-8. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure.
Article 370-28 Pull and Junction Boxes. Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d) of this section.
(c) Covers. All pull boxes shall be provided with covers compatible with the box.

Based on observation and staff interview, the facility failed to ensure an alcohol based hand rub (ABHR) dispenser was not installed over an ignition source in 1 of 4 smoke compartments. The findings were:

Observation on 11/15/11 at 9:48 AM revealed one ABHR dispenser was attached to the wall directly over a light switch in the outpatient entrance. Interview with the maintenance manager at the time of the observation confirmed the dispenser was located over a possible ignition source.

Reference: NFPA 101, Life Safety Code, 2000 edition,
Section 19.3.2.7. CFR 403.744.

Based on observation and staff interview, the facility failed to ensure one smoke barrier door was resistant to the passage of smoke in 1 of 4 smoke compartments. The findings were:

Observation on 11/15/11 at 12:48 PM revealed the cross corridor smoke barrier double doors between the laundry and physical therapy were held open with maglocks. However, upon release, the doors were unable to close completely. The maintenance manager confirmed the finding at the time of the observation.

Reference: NFPA 101, Life Safety Code, 2000 edition
19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self closing or automatic closing in accordance with 19.2.2.2.6.
8.3.4.1 Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be withour undercuts, louvers, or grilles.

Based on observation and staff interview, the facility failed to ensure 6 of 14 emergency exit lights were properly illuminated. The findings were:

Observations on 11/15/11 between 11:45 AM and 2:48 PM revealed six emergency exit lights had one of two light bulbs burned out in the following locations:
a. Over the door between the kitchen and the staff dining room.
b. Over the door between the kitchen and the main hallway.
c. Over the main entrance into the reception area.
d. In the hallway by the administration office and cross corridor doors.
e. Over the door between the emergency room hallway and the ambulance area.
f. Over the door between the ambulance area and the ambulance garage.
Interview with the maintenance manager at the time of the observations confirmed the bulbs were burned out.

Reference: NFPA 101, Life Safety Code, 2000 edition.
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.
7.10.5.1 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 Setion 7.8.
7.8.1.4 Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less that 0.2 ft-candles.

Based on record review and staff interview the facility failed to ensure the fire suppression (sprinkler) system was properly maintained in 1 of 4 smoke compartments. The findings were:

Observations on 11/15/11 at 1:48 PM revealed a ceiling mounted sprinkler head was blocked by moping materials in the janitor's store room (mop/washer room). Interview with the maintenance manager at the above time confirmed the observation.

Ref: 2000 NFPA 101 Section 18.3.5.1; 9.7.1.1; NFPA 13, 1999 edition
5-5.6 Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 in or greater.

Based on observation and staff interview, the facility failed to inspect 4 of 25 portable fire extinguishers during the previous year in accordance with NFPA 10 Section 4-4.1. The findings were:

Observation of facility fire extinguishers on 11/15/11 between 11:45 AM and 2:48 PM revealed an inspection tag dated 2009 was attached to the fire extinguishers located in the lab, the maintenance room and the procedure room. In addition, an inspection tag dated 2008 was attached to the fire extinguisher in the central supply room. Interview with facility manager at the times listed above confirmed the extinguishers were improperly tagged.

NFPA 101, Life Safety Code, 2000 edition.
Sections 19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10.
4-4.1 Maintenance Frequency. Extinguishers shall be subjected to maintenance not more than one year apart or when specifically indicated by an inspection.

Based on observation and staff interview, the facility failed to ensure compliance with the National Electric Code in 2 of 4 smoke compartments. The findings were:

Observations on 11/15/11 between 11:45 AM and 2:48 PM revealed a surge protector was plugged into another surge protector in the emergency services office, in the nursing office, and in the medical records office. Plugged into the surge protectors were business machines, including computers, printers. In addition, a dimmer wall light switch was missing an electrical cover in the xray procedure room and the wall light switch in resident room #7 was cracked. Interview with the maintenance manager at the time of the observations confirmed the above findings.

Reference: NFPA 70, National Electrical Code, 1999 Edition.
Article 400-8. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure.
Article 370-28 Pull and Junction Boxes. Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d) of this section.
(c) Covers. All pull boxes shall be provided with covers compatible with the box.