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Based on observation and staff interview, the facility failed to provide 2-hour rated construction at the building separation walls in accordance with 2000 - NFPA 101, sections 19.1.1.4, 19.1.2.3 and 8.2.3.2.


Findings include:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, observation revealed the following in the 2-hour fire rated building separation walls between the following locations:

1. Hospital and the ambulance garage, no positive latching on double doors

2. Hospital and the clinic, there are several open penetrations above the ceiling panels


These deficient practices were confirmed by the Director of Maintenance (BA) at the time of discovery.

Based on observation and staff interview, the facility had a corridor door which were impeded from fully closing and latching into it's frame in accordance with the requirements of 2000 NFPA 101, Sections 18.3.6.3.2.

FINDINGS INCLUDE:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, observation revealed that the north and south doors from kitchen area that opens into the corridor does not have positive latching hardware.


This deficient practice was confirmed by Director of Facility Maintenance (BA) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain smoke-resisting partitions and doors in accordance with the following requirements of 2000 NFPA 101, Section 19.3.2.1.


Findings include:


On facility tour between 0945 AM and 4:00 PM on 09/25/2013, observation revealed that the following was found:

1. Emergency room, the soiled utility room door does not have an automatic door closer

2. Mechanical room # S-4, the following was found:
a. room door does not have an automatic door closer
b. gap between double doors is over 1/8 of an inch

3. Housekeeping/storage room (over 50 sq. ft.), does not have an automatic door closer

4. Clean linen room (over 50 sq. ft.), does not have an automatic door closer


These deficient practices were confirmed by the Director of Maintenance (BA) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide reliable lighting as required by 2000 NFPA 101, Section 19..2.9.1, 7.9.3, 7.10.9.

Findings include:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, the review of the battery operated emergency lighting and exit sign testing documentation for the past 12 months revealed, that the facility failed to conduct monthly 30 second and yearly 90 minute testing and document such since May 2012.


This deficient practice was confirmed by the Director of Maintenance (BA) at the time of discovery.

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift per quarter for all staff under varying times and conditions as required by 2000 NFPA 101, Section 18.7.1.2.


Findings include:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, the review of the fire drill documentation for the past 12 months (October 2012 to September 2013) revealed that the following was found:

1. The following fire drills were missed:
a. 2012 - 4th quarter - Day & Evening shifts
b. 2013 - 1st quarter - Night shift
c. 2013 - 2nd quarter - Day & evening shifts
d. 2012/2013 - 3rd quarter - Night shift

2. The drills for the following shifts were completed but did not sufficiently vary the times that the drills were conducted:
Day - 1057 & 1100 hours
Night - 0630 & 0600 hours


These deficient practices were confirmed by Director of Facility Maintenance (BA) at the time of discovery.

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift per quarter for all staff under varying times and conditions as required by 2000 NFPA 101, Section 19.7.1.2.


Findings include:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, the review of the fire drill documentation for the past 12 months (October 2012 to September 2013) revealed that the following was found:

1. The following fire drills were missed:
a. 2012 - 4th quarter - Day & Evening shifts
b. 2013 - 1st quarter - Night shift
c. 2013 - 2nd quarter - Day & evening shifts
d. 2012/2013 - 3rd quarter - Night shift

2. The drills for the following shifts were completed but did not sufficiently vary the times that the drills were conducted:
Day - 1057 & 1100 hours
Night - 0630 & 0600 hours


These deficient practices were confirmed by Director of Facility Maintenance (BA) at the time of discovery.

Based on observation and staff interview, the facility failed to test the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 18.3.4.1 and 9.6, as well as 1999 NFPA 72 Tables 7-2.2 (16) (b).

Findings include:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, observation revealed that the primary and secondary transmission lines were tested by unplugging each phone line and revealed, that there was no trouble signal with-in 4 minutes to the premises fire alarm system. It was verified that the monitoring company did receive both of the trouble signals.


This deficient practice was confirmed by Director of Facility Maintenance (BA) at the time of discovery.

Based on observation and staff interview, the facility failed to test the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72 Tables 7-2.2 (16) (b).

Findings include:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, observation revealed that the following were found:

1. The primary and secondary transmission lines were tested by unplugging each phone line and revealed, that there was no trouble signal with-in 4 minutes to the premises fire alarm system. It was verified that the monitoring company did receive both of the trouble signals.

2. Smoke detectors D013, D059 and D065 are located with-in the air flow of supply or return vents

NOTE: Check the entire facility for # 2 deficiency


These deficient practices were confirmed by Director of Facility Maintenance (BA) at the time of discovery.

Based on documentation review and staff interview, the facility failed maintain the fire alarm system in accordance with the requirement 1999 NFPA 72, Sections 7-3.2 and 7-3.2.1.

Findings include:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, the review of the following reports found the following:

1. The annual fire alarm system inspection / test was not completed in a 12 month period. The report from Fire Fighter Detect Alarm indicated the 2011 was completed on 04/21/2011 and 2012 was completed on 10/04/2012.

2. No bi-annual sensitivity testing has been completed since 04/21/2012


These deficient practices were confirmed by Director of Facility Maintenance (BA) at the time of discovery.

Based on documentation review and staff interview, that the facility's general ventilating and air conditioning system (HVAC) was not maintained in accordance with the LSC, Section 18.5.2.1 and NFPA 90A, Section 3-4.7. A noncompliant HVAC system.

Findings include:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, documentation review of the fire damper testing for the past 4 years revealed, that the fire/smoke dampers have not been tested.


This deficient practice was confirmed by Director of Facility Maintenance (BA) at the time of discovery.

Based on documentation review and staff interview, the facility's kitchen cooking hood fire extinguishing system was not maintained in accordance with 2000 NFPA 101 - 9.2.3 and 1998 NFPA 96 section 8.2..

Findings include:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, the review of the kitchen hood system inspection documentation for the past 12 months revealed that the kitchen hood was not inspected every 6 months (02/11/13 and 09/25/2013).

This deficient practice was confirmed by Director of Facility Maintenance (BA) at the time of discovery.

Based on observation and staff interview, the facility failed to assure the pipe medical gas system is labeled and tested as required by 1999 NFPA 99 Chapter 4-3.5.2.3 (i).

Findings include:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, the review of the medical gas alarm system testing documentation revealed, that the testing of audible and visual alarm indicators have not been tested in the past 12 months.

This deficient practice was confirmed by Director of Facility Maintenance (BA) at the time of discovery.

Based on documentation review and staff interview, the facility failed to test the emergency generators in accordance with the requirements of 2000 NFPA 101 - 9.1.3 and 1999 NFPA 110 6-4.2 (a) & (b) and 6-4.2.2.

Findings include:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, documentation review of the monthly emergency generator testing logs (October 2012 to September 2013), indicated that the facility did not run the diesel emergency generator at 30% of nameplate rating or by one of the following means. Last documented load bank test was 05/09/2012.

a. loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer or
b. under load of 30 percent or more of the nameplate rating of generator or
c. 2 hour load bank test ( first 30 minutes - 25%, next 30 minutes - 50%, and last 1 hour - 75%)

This deficient practice was confirmed by Director of Facility Maintenance (BA) at the time of discovery.



*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.

Based on observation and staff interview, the facility failed to provide 2-hour rated construction at the building separation walls in accordance with 2000 - NFPA 101, sections 19.1.1.4, 19.1.2.3 and 8.2.3.2.


Findings include:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, observation revealed the following in the 2-hour fire rated building separation walls between the following locations:

1. Hospital and the ambulance garage, no positive latching on double doors

2. Hospital and the clinic, there are several open penetrations above the ceiling panels


These deficient practices were confirmed by the Director of Maintenance (BA) at the time of discovery.

Based on observation and staff interview, the facility had a corridor door which were impeded from fully closing and latching into it's frame in accordance with the requirements of 2000 NFPA 101, Sections 18.3.6.3.2.

FINDINGS INCLUDE:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, observation revealed that the north and south doors from kitchen area that opens into the corridor does not have positive latching hardware.


This deficient practice was confirmed by Director of Facility Maintenance (BA) at the time of discovery.

Based on observation and staff interview, the facility failed to maintain smoke-resisting partitions and doors in accordance with the following requirements of 2000 NFPA 101, Section 19.3.2.1.


Findings include:


On facility tour between 0945 AM and 4:00 PM on 09/25/2013, observation revealed that the following was found:

1. Emergency room, the soiled utility room door does not have an automatic door closer

2. Mechanical room # S-4, the following was found:
a. room door does not have an automatic door closer
b. gap between double doors is over 1/8 of an inch

3. Housekeeping/storage room (over 50 sq. ft.), does not have an automatic door closer

4. Clean linen room (over 50 sq. ft.), does not have an automatic door closer


These deficient practices were confirmed by the Director of Maintenance (BA) at the time of discovery.

This STANDARD is not met as evidenced by:

Based on observation and staff interview, the facility failed to provide reliable lighting as required by 2000 NFPA 101, Section 19..2.9.1, 7.9.3, 7.10.9.

Findings include:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, the review of the battery operated emergency lighting and exit sign testing documentation for the past 12 months revealed, that the facility failed to conduct monthly 30 second and yearly 90 minute testing and document such since May 2012.


This deficient practice was confirmed by the Director of Maintenance (BA) at the time of discovery.

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift per quarter for all staff under varying times and conditions as required by 2000 NFPA 101, Section 18.7.1.2.


Findings include:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, the review of the fire drill documentation for the past 12 months (October 2012 to September 2013) revealed that the following was found:

1. The following fire drills were missed:
a. 2012 - 4th quarter - Day & Evening shifts
b. 2013 - 1st quarter - Night shift
c. 2013 - 2nd quarter - Day & evening shifts
d. 2012/2013 - 3rd quarter - Night shift

2. The drills for the following shifts were completed but did not sufficiently vary the times that the drills were conducted:
Day - 1057 & 1100 hours
Night - 0630 & 0600 hours


These deficient practices were confirmed by Director of Facility Maintenance (BA) at the time of discovery.

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift per quarter for all staff under varying times and conditions as required by 2000 NFPA 101, Section 19.7.1.2.


Findings include:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, the review of the fire drill documentation for the past 12 months (October 2012 to September 2013) revealed that the following was found:

1. The following fire drills were missed:
a. 2012 - 4th quarter - Day & Evening shifts
b. 2013 - 1st quarter - Night shift
c. 2013 - 2nd quarter - Day & evening shifts
d. 2012/2013 - 3rd quarter - Night shift

2. The drills for the following shifts were completed but did not sufficiently vary the times that the drills were conducted:
Day - 1057 & 1100 hours
Night - 0630 & 0600 hours


These deficient practices were confirmed by Director of Facility Maintenance (BA) at the time of discovery.

Based on observation and staff interview, the facility failed to test the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 18.3.4.1 and 9.6, as well as 1999 NFPA 72 Tables 7-2.2 (16) (b).

Findings include:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, observation revealed that the primary and secondary transmission lines were tested by unplugging each phone line and revealed, that there was no trouble signal with-in 4 minutes to the premises fire alarm system. It was verified that the monitoring company did receive both of the trouble signals.


This deficient practice was confirmed by Director of Facility Maintenance (BA) at the time of discovery.

Based on observation and staff interview, the facility failed to test the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72 Tables 7-2.2 (16) (b).

Findings include:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, observation revealed that the following were found:

1. The primary and secondary transmission lines were tested by unplugging each phone line and revealed, that there was no trouble signal with-in 4 minutes to the premises fire alarm system. It was verified that the monitoring company did receive both of the trouble signals.

2. Smoke detectors D013, D059 and D065 are located with-in the air flow of supply or return vents

NOTE: Check the entire facility for # 2 deficiency


These deficient practices were confirmed by Director of Facility Maintenance (BA) at the time of discovery.

Based on documentation review and staff interview, the facility failed maintain the fire alarm system in accordance with the requirement 1999 NFPA 72, Sections 7-3.2 and 7-3.2.1.

Findings include:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, the review of the following reports found the following:

1. The annual fire alarm system inspection / test was not completed in a 12 month period. The report from Fire Fighter Detect Alarm indicated the 2011 was completed on 04/21/2011 and 2012 was completed on 10/04/2012.

2. No bi-annual sensitivity testing has been completed since 04/21/2012


These deficient practices were confirmed by Director of Facility Maintenance (BA) at the time of discovery.

Based on documentation review and staff interview, that the facility's general ventilating and air conditioning system (HVAC) was not maintained in accordance with the LSC, Section 18.5.2.1 and NFPA 90A, Section 3-4.7. A noncompliant HVAC system.

Findings include:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, documentation review of the fire damper testing for the past 4 years revealed, that the fire/smoke dampers have not been tested.


This deficient practice was confirmed by Director of Facility Maintenance (BA) at the time of discovery.

Based on documentation review and staff interview, the facility's kitchen cooking hood fire extinguishing system was not maintained in accordance with 2000 NFPA 101 - 9.2.3 and 1998 NFPA 96 section 8.2..

Findings include:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, the review of the kitchen hood system inspection documentation for the past 12 months revealed that the kitchen hood was not inspected every 6 months (02/11/13 and 09/25/2013).

This deficient practice was confirmed by Director of Facility Maintenance (BA) at the time of discovery.

Based on observation and staff interview, the facility failed to assure the pipe medical gas system is labeled and tested as required by 1999 NFPA 99 Chapter 4-3.5.2.3 (i).

Findings include:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, the review of the medical gas alarm system testing documentation revealed, that the testing of audible and visual alarm indicators have not been tested in the past 12 months.

This deficient practice was confirmed by Director of Facility Maintenance (BA) at the time of discovery.

Based on documentation review and staff interview, the facility failed to test the emergency generators in accordance with the requirements of 2000 NFPA 101 - 9.1.3 and 1999 NFPA 110 6-4.2 (a) & (b) and 6-4.2.2.

Findings include:

On facility tour between 0945 AM and 4:00 PM on 09/25/2013, documentation review of the monthly emergency generator testing logs (October 2012 to September 2013), indicated that the facility did not run the diesel emergency generator at 30% of nameplate rating or by one of the following means. Last documented load bank test was 05/09/2012.

a. loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer or
b. under load of 30 percent or more of the nameplate rating of generator or
c. 2 hour load bank test ( first 30 minutes - 25%, next 30 minutes - 50%, and last 1 hour - 75%)

This deficient practice was confirmed by Director of Facility Maintenance (BA) at the time of discovery.



*TEAM COMPOSITION*
Gary Schroeder, Life Safety Code Spc.