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The facility failed to provide a permitted building type. Findings include:

During the survey, the following are examples of what was observed:

1. Throughout the facility the elements of the ceiling assembly did not meet the requirements for a UL rated assembly, as required in non sprinklered facilities. Five different kinds of ceiling tile were observed throughout the facility, hold down clips were not observed and the ceiling assembly grid could not be verified that it was fire rated (except in one place - in the corridor outside the Billing Office).
2. The rooms on the 200 Hall - the TV hanger pipe had been cut off leaving a penetration in the ceiling.
3. Room 221 also had a single wire penetration of the ceiling by the TV hanger pipe.
4. Room 222 also had a hole in the ceiling.
5. Room 111 also had a hole in the ceiling, approximately 2' X 2' from a roof leak.

2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
.

The facility failed to provide corridor walls that would provide at least a 30 minute fire resistance rating. Findings include: During the survey, the following are examples of what was observed:

1. Unsealed penetrations in the corridor wall around wiring, above the ceiling at the Lab.
2. Unsealed penetrations in the corridor wall, at the end of a sleeve, above the ceiling at the entrance to the Emergency Room.
3. Unsealed penetrations at the deck of the corridor wall, in three separate locations above the ceiling at the entrance to the kitchen, and Dining Room.

NFPA 101, 19.3.6.1 Corridors in unsprinklered smoke compartments shall be separated from all other areas by partitions having a fire resistance rating of at least 30 minutes.

The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include:

During the survey, the following are examples of what was observed:

1. Patient Room 109 door failed to close tight in the frame.

2. Patient Room 107 door failed to close tight in the frame.

3. Two Emergency Room doors were not positive latching, doors open into the corridor.


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4. The Laboratory Room, next to Admissions Switchboard, the corridor door had a roller latch.

5. The following corridor doors had unsealed pentrations at the door knobs making them not smoke resistive:

a. Admissions Switchboard
b. Room 200
c. Room 208
d. Room 218

6. The Employee Toilet, at the Nurses' Station, found the corridor door not to be smoke resistive.

7. The Bathing Room, across from room 210, the corridor door was not smoke resistive.

2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

.

The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include:

During the survey, the following are examples of what was observed:

Unsealed penetrations around a section of conduit in the Smoke Barrier by the Billing Office.

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 maintain the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:

1. Room 111 - was being used for combustible storage, the room is over 50 sq. ft. and was not sprinklered:
a. This room did not have a 45 minute fire rated door
b. The door did not have a self-closing device

2. The Supply Room - was being used for combustible storage, the room did have sprinkler coverage, the room is over 100 sq. ft.:
a. The door to the Lobby did not have positive latching hardware
b. The Office door connected to the Supply Room did not have a self-closing device

3. The Dietary Storage Room was being used for combustible storage, the room did not have sprinkler coverage, the room was over 50 sq. ft.:
a. The door was not 45 minute fire rated
b. The door did not have a self-closing device

2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

2000 NFPA 101, 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.
.

The facility failed to provide a reliable means of egress to the public way:

Findings include: During the survey, the following are examples of what was observed:

1. The Exit Discharge for the Exit by Patient Room 111 was not provided with an all weather surface to the public way.


27382

2. The Northeast Exit was observed with stairs that ended in a grassy area.

2000 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.
2000 NFPA 101, 7.7.1 Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.
.

The facility failed to provide a complete fire evacuation plan per code. Findings include:

The fire evacuation plan did not include "evacuation of smoke compartments", it was a total evacuation of the building.

2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment***
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
.

The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey, the sprinkler documentation provided by the facility of the sprinkler inspections/testing were dated:

02/21/2011
03/22/2010

The facility is doing annual inspections/testing of the automatic sprinkler sytem.

2000 NFPA 101, 9.7.5 All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
.

A) During the survey, the following are examples of what was observed:

This surveyor observed excessive amount of smoking materials on the ground at the Exit Discharge for the Exit by Patient Room 111. The facility had provided a smoke tower for the discarded cigarette butts to be placed after use.

NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays shall be provided.


27382


B) During the survey the facility failed to provide a copy of the smoking policy.

2000 NFPA 101, 19.7.4 Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies, where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
.

The facility had improper heating devices. Findings include:

During the survey, the following are examples of what was observed:

A portable electrical heater was in Patient room 101.

NFPA 101, 19.7.8, prohibits the use of portable space heating devices.

The facility failed to maintain the electrical system per code. Findings include:

During the survey, the following is an example of what was observed a refrigerator plugged into a surge protector in the Billing Office

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

.

The facility failed to provide a written plan of action for sprinkler system shutdown.

NFPA 101, 9.7.6.1 When a required automatic sprinkler system is out of service for more than 4-hours in a 24-hour period, an approved fire watch shall be provided or the building shall be evacuated .

The facility failed to provide to provide a written plan for the fire alarm system shutdown.

NFPA 101, 9.6.8.1 Where a required fire alarm system is out of service for more than 4-hours in a 24-hour period, an approved fire watch shall be provided or the building shall be evacuated .

The facility failed to provide a permitted building type. Findings include:

During the survey, the following are examples of what was observed:

1. Throughout the facility the elements of the ceiling assembly did not meet the requirements for a UL rated assembly, as required in non sprinklered facilities. Five different kinds of ceiling tile were observed throughout the facility, hold down clips were not observed and the ceiling assembly grid could not be verified that it was fire rated (except in one place - in the corridor outside the Billing Office).
2. The rooms on the 200 Hall - the TV hanger pipe had been cut off leaving a penetration in the ceiling.
3. Room 221 also had a single wire penetration of the ceiling by the TV hanger pipe.
4. Room 222 also had a hole in the ceiling.
5. Room 111 also had a hole in the ceiling, approximately 2' X 2' from a roof leak.

2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
.

The facility failed to provide corridor walls that would provide at least a 30 minute fire resistance rating. Findings include: During the survey, the following are examples of what was observed:

1. Unsealed penetrations in the corridor wall around wiring, above the ceiling at the Lab.
2. Unsealed penetrations in the corridor wall, at the end of a sleeve, above the ceiling at the entrance to the Emergency Room.
3. Unsealed penetrations at the deck of the corridor wall, in three separate locations above the ceiling at the entrance to the kitchen, and Dining Room.

NFPA 101, 19.3.6.1 Corridors in unsprinklered smoke compartments shall be separated from all other areas by partitions having a fire resistance rating of at least 30 minutes.

The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include:

During the survey, the following are examples of what was observed:

1. Patient Room 109 door failed to close tight in the frame.

2. Patient Room 107 door failed to close tight in the frame.

3. Two Emergency Room doors were not positive latching, doors open into the corridor.


27382


4. The Laboratory Room, next to Admissions Switchboard, the corridor door had a roller latch.

5. The following corridor doors had unsealed pentrations at the door knobs making them not smoke resistive:

a. Admissions Switchboard
b. Room 200
c. Room 208
d. Room 218

6. The Employee Toilet, at the Nurses' Station, found the corridor door not to be smoke resistive.

7. The Bathing Room, across from room 210, the corridor door was not smoke resistive.

2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

.

The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include:

During the survey, the following are examples of what was observed:

Unsealed penetrations around a section of conduit in the Smoke Barrier by the Billing Office.

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 maintain the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:

1. Room 111 - was being used for combustible storage, the room is over 50 sq. ft. and was not sprinklered:
a. This room did not have a 45 minute fire rated door
b. The door did not have a self-closing device

2. The Supply Room - was being used for combustible storage, the room did have sprinkler coverage, the room is over 100 sq. ft.:
a. The door to the Lobby did not have positive latching hardware
b. The Office door connected to the Supply Room did not have a self-closing device

3. The Dietary Storage Room was being used for combustible storage, the room did not have sprinkler coverage, the room was over 50 sq. ft.:
a. The door was not 45 minute fire rated
b. The door did not have a self-closing device

2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

2000 NFPA 101, 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.
.

The facility failed to provide a reliable means of egress to the public way:

Findings include: During the survey, the following are examples of what was observed:

1. The Exit Discharge for the Exit by Patient Room 111 was not provided with an all weather surface to the public way.


27382

2. The Northeast Exit was observed with stairs that ended in a grassy area.

2000 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.
2000 NFPA 101, 7.7.1 Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.
.

The facility failed to provide a complete fire evacuation plan per code. Findings include:

The fire evacuation plan did not include "evacuation of smoke compartments", it was a total evacuation of the building.

2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment***
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
.

The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey, the sprinkler documentation provided by the facility of the sprinkler inspections/testing were dated:

02/21/2011
03/22/2010

The facility is doing annual inspections/testing of the automatic sprinkler sytem.

2000 NFPA 101, 9.7.5 All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
.

A) During the survey, the following are examples of what was observed:

This surveyor observed excessive amount of smoking materials on the ground at the Exit Discharge for the Exit by Patient Room 111. The facility had provided a smoke tower for the discarded cigarette butts to be placed after use.

NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays shall be provided.


27382


B) During the survey the facility failed to provide a copy of the smoking policy.

2000 NFPA 101, 19.7.4 Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies, where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
.

The facility had improper heating devices. Findings include:

During the survey, the following are examples of what was observed:

A portable electrical heater was in Patient room 101.

NFPA 101, 19.7.8, prohibits the use of portable space heating devices.

The facility failed to maintain the electrical system per code. Findings include:

During the survey, the following is an example of what was observed a refrigerator plugged into a surge protector in the Billing Office

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

.

The facility failed to provide a written plan of action for sprinkler system shutdown.

NFPA 101, 9.7.6.1 When a required automatic sprinkler system is out of service for more than 4-hours in a 24-hour period, an approved fire watch shall be provided or the building shall be evacuated .

The facility failed to provide to provide a written plan for the fire alarm system shutdown.

NFPA 101, 9.6.8.1 Where a required fire alarm system is out of service for more than 4-hours in a 24-hour period, an approved fire watch shall be provided or the building shall be evacuated .