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The facility failed to maintain the construction type per code. Findings include:

During the survey, the following are examples of what was observed:
The following rooms were observed with missing and broken ceiling tiles:
1. I.T. (Computer Room)
2. Pharmacy

_______________

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 maintain the corridor walls in the non sprinklered section of the facility per code. Findings include:

During the survey, the following is an example of what was observed:
The corridor wall for the Soiled Utility Room had an unsealed penetration of both sides of the corridor wall of three flex conduits

______________

2000 NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
.

The facility failed to maintain the smoke barrier per code. Findings include:

During the survey, the following are examples of what was observed:
The smoke barrier had the following unsealed penetrations:
1. The corridor smoke barrier at the Soiled Utility Room - a group of blue wires
2. The smoke barrier in the Soiled Utility Room - three flex conduits
3. The corridor smoke barrier at room 200 (D.O.N.'s Office) - red wires at the bottom left corner of the HVAC duct
4. The smoke barrier in the Patient Accounts Supervisor's Office - ten unsealed penetrations below the ceiling

______________

2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows:
(1) The space between the penetrating item and the smoke partition shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions:a. It shall be filled with a material that is capable of limiting the transfer of smoke.b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke partitions.
b. It shall be made by an approved device that is designed for the specific purpose.
.

The facility failed to maintain separation of hazardous areas. Findings include: During the survey, the following is an example of what was observed.

Two holes in the ceiling of the combustible x-ray storage room, across the corridor from the x-ray room. This room is not provided with sprinkler coverage.




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.

The facility failed to maintain the exit access per code. Findings include:

During the survey, the following are examples of what was observed:
The following doors had more than one releasing operation:
1. Room 221 (Home Health) - thumb latch deadbolt and door knob
2. Kitchen corridor door - double keyed deadbolt and door knob

________________

2000 NFPA 101, 7.2.1.5.4 A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
.

The facility failed to maintain the exit and directional lighting per code. Findings include:

During the survey, the following is an example of what was observed:
The exit sign at room 223 - the directional arrows sent you into rooms without exits

_____________

2000 NFPA 101, 7.10.1.3 Tactile signage shall be located at each door into an exit stair enclosure, and such signage shall read as follows:
EXIT
Signage shall comply with CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, and shall be installed adjacent to the latch side of the door 60 in. (152 cm) above the finished floor to the centerline of the sign.
.

The facility failed to conduct fire drills per code. Findings include:

During the survey, the following are examples of what was observed:
FIRST SHIFT
Fourth Quarter
11/30/13 - 10:30 am
Third Quarter
NO DRILL
Second Quarter
06/17/13 - 11:02 am
05/31/13 - 11:15 am
04/12/13 - 9:30 am
First Quarter
02/13/13 - 9:20 am

SECOND SHIFT
First Quarter 2014
01/13/14 - 6:15 pm
Fourth Quarter
10/31/13 - 10:30 pm
Third Quarter
07/20/13 - 8:25 pm
Second Quarter
NO DRILL

THIRD SHIFT
Fourth Quarter
12/31/13 - 3:20 am
Third Quarter
09/22/13 - 12:10 am
08/03/13 - 2:11 am
Second Quarter
NO DRILL
First Quarter
01/15/13 - 1:25 am

___________________

2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
.

The facility failed to provide current documentation of the inspection of the fire alarm system. During the survey, the following is an example of what was observed.


Documentation was not provided for the annual inspection of the fire alarm system.


1999 NFPA 72, 7-5.2.2 and Figure 7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be maintained which includes periodic tests and applicable information.

The facility failed to perform sensitivity testing of the smoke detectors. Findings include:

Documentation provided by the facility during the survey did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following is an example of what was observed.

Ceiling tiles missing in the Central Supply storage room; this area is provided with sprinkler coverage.

NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.

The facility failed to perform the required maintenance of the facility sprinkler system. Findings include: During the survey, the following is an example of what was observed.


The only documentation provided by the facility for the quarterly sprinkler inspections was conducted on 11/19/2013.


NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).

A. The facility failed to provide required height for fire extinguishers. Findings
include: During the survey, the following is an example of what was observed.

The fire extinguisher located in the kitchen was mounted on a hook measured 66" from the floor to the top of the gauge.

1998 NFPA 10, 1-6.10 Fire extinguishers weighting not more than 40 lb. (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb. (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).


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B. The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following are examples of what was observed:
1. Fire extinguishers throughout the facility had their annual inspection in November 2013, there was no documentation of a monthly inspection in December 2013
2. The fire extinguisher in room 221 (Home Health) last annual inspection date was 2012

________________

1998 NFPA 10, 4-3.4.1 Personnel making inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action.

1998 NFPA 10, 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

1998 NFPA 10, 4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

1998 NFPA 10, 4-3.1 Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

1998 NFPA 10, 4-4.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

.

The facility failed to provide proper cooking appliances. Findings include: During the survey, the following is an example of what was observed.


The deep fryer was observed without the required separation from the open flames on the stove top. Approximately 3" inch gap was observed between the open flame and the deep fryer.


NFPA 96, 9-1.2.3 A space of 16" shall be provided between the deep fryer and surface flames from adjacent cooking equipment, or have an installed steel or tempered glass baffle plate at a minimum of 8" high.

The facility had improper heating devices. Findings include: During the survey, the following is an example of what was observed.


A portable electrical heater in the Doctor's Sleeping Lounge.


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

The facility failed to provide a readily accessible means of egress pathway at all times. Findings include: During the survey, the following is an example of what was observed.

A vehicle was parked across the sidewalk , obstructing the means of egress to the public way at the Northeast Exit.


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

The facility failed to provide proper storage of oxygen cylinders. Findings include: During the survey, the following is an example of what was observed.


Eight unsecured oxygen cylinders in the outside storage area.


1999 NFPA 99, 4-3.1.1.1 and 4-5.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

The facility failed to maintain approved electrical utilities. Findings include: During the survey, the following is an example of what was observed.


1. A junction box was missing the cover in the wash room of the kitchen.


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2. D.O.N.'s Office had a refrigerator plugged into a surge protector (extension cord), plugged into another surge protector (extension cord)
3. I.T. (Computer) Room had an electrical junction box missing it's cover plate
4. Patient's Accounts Supervisor's Office had an electrical outlet missing it's cover plate
5. Accounting had a refrigerator plugged into a surge protector (extension cord)

____________

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

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.


1999 NFPA 70, 370-28. Pull and Junction Boxes
Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d).
(a) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.

The facility failed to maintain the construction type per code. Findings include:

During the survey, the following are examples of what was observed:
The following rooms were observed with missing and broken ceiling tiles:
1. I.T. (Computer Room)
2. Pharmacy

_______________

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 maintain the corridor walls in the non sprinklered section of the facility per code. Findings include:

During the survey, the following is an example of what was observed:
The corridor wall for the Soiled Utility Room had an unsealed penetration of both sides of the corridor wall of three flex conduits

______________

2000 NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
.

The facility failed to maintain the smoke barrier per code. Findings include:

During the survey, the following are examples of what was observed:
The smoke barrier had the following unsealed penetrations:
1. The corridor smoke barrier at the Soiled Utility Room - a group of blue wires
2. The smoke barrier in the Soiled Utility Room - three flex conduits
3. The corridor smoke barrier at room 200 (D.O.N.'s Office) - red wires at the bottom left corner of the HVAC duct
4. The smoke barrier in the Patient Accounts Supervisor's Office - ten unsealed penetrations below the ceiling

______________

2000 NFPA 101, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows:
(1) The space between the penetrating item and the smoke partition shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions:a. It shall be filled with a material that is capable of limiting the transfer of smoke.b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke partitions.
b. It shall be made by an approved device that is designed for the specific purpose.
.

The facility failed to maintain separation of hazardous areas. Findings include: During the survey, the following is an example of what was observed.

Two holes in the ceiling of the combustible x-ray storage room, across the corridor from the x-ray room. This room is not provided with sprinkler coverage.




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.

The facility failed to maintain the exit access per code. Findings include:

During the survey, the following are examples of what was observed:
The following doors had more than one releasing operation:
1. Room 221 (Home Health) - thumb latch deadbolt and door knob
2. Kitchen corridor door - double keyed deadbolt and door knob

________________

2000 NFPA 101, 7.2.1.5.4 A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
.

The facility failed to maintain the exit and directional lighting per code. Findings include:

During the survey, the following is an example of what was observed:
The exit sign at room 223 - the directional arrows sent you into rooms without exits

_____________

2000 NFPA 101, 7.10.1.3 Tactile signage shall be located at each door into an exit stair enclosure, and such signage shall read as follows:
EXIT
Signage shall comply with CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, and shall be installed adjacent to the latch side of the door 60 in. (152 cm) above the finished floor to the centerline of the sign.
.

The facility failed to conduct fire drills per code. Findings include:

During the survey, the following are examples of what was observed:
FIRST SHIFT
Fourth Quarter
11/30/13 - 10:30 am
Third Quarter
NO DRILL
Second Quarter
06/17/13 - 11:02 am
05/31/13 - 11:15 am
04/12/13 - 9:30 am
First Quarter
02/13/13 - 9:20 am

SECOND SHIFT
First Quarter 2014
01/13/14 - 6:15 pm
Fourth Quarter
10/31/13 - 10:30 pm
Third Quarter
07/20/13 - 8:25 pm
Second Quarter
NO DRILL

THIRD SHIFT
Fourth Quarter
12/31/13 - 3:20 am
Third Quarter
09/22/13 - 12:10 am
08/03/13 - 2:11 am
Second Quarter
NO DRILL
First Quarter
01/15/13 - 1:25 am

___________________

2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
.

The facility failed to provide current documentation of the inspection of the fire alarm system. During the survey, the following is an example of what was observed.


Documentation was not provided for the annual inspection of the fire alarm system.


1999 NFPA 72, 7-5.2.2 and Figure 7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be maintained which includes periodic tests and applicable information.

The facility failed to perform sensitivity testing of the smoke detectors. Findings include:

Documentation provided by the facility during the survey did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following is an example of what was observed.

Ceiling tiles missing in the Central Supply storage room; this area is provided with sprinkler coverage.

NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.

The facility failed to perform the required maintenance of the facility sprinkler system. Findings include: During the survey, the following is an example of what was observed.


The only documentation provided by the facility for the quarterly sprinkler inspections was conducted on 11/19/2013.


NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).

A. The facility failed to provide required height for fire extinguishers. Findings
include: During the survey, the following is an example of what was observed.

The fire extinguisher located in the kitchen was mounted on a hook measured 66" from the floor to the top of the gauge.

1998 NFPA 10, 1-6.10 Fire extinguishers weighting not more than 40 lb. (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb. (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).


27382


B. The facility failed to maintain the fire extinguishers per code. Findings include:

During the survey, the following are examples of what was observed:
1. Fire extinguishers throughout the facility had their annual inspection in November 2013, there was no documentation of a monthly inspection in December 2013
2. The fire extinguisher in room 221 (Home Health) last annual inspection date was 2012

________________

1998 NFPA 10, 4-3.4.1 Personnel making inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action.

1998 NFPA 10, 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

1998 NFPA 10, 4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

1998 NFPA 10, 4-3.1 Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

1998 NFPA 10, 4-4.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

.

The facility failed to provide proper cooking appliances. Findings include: During the survey, the following is an example of what was observed.


The deep fryer was observed without the required separation from the open flames on the stove top. Approximately 3" inch gap was observed between the open flame and the deep fryer.


NFPA 96, 9-1.2.3 A space of 16" shall be provided between the deep fryer and surface flames from adjacent cooking equipment, or have an installed steel or tempered glass baffle plate at a minimum of 8" high.

The facility had improper heating devices. Findings include: During the survey, the following is an example of what was observed.


A portable electrical heater in the Doctor's Sleeping Lounge.


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

The facility failed to provide a readily accessible means of egress pathway at all times. Findings include: During the survey, the following is an example of what was observed.

A vehicle was parked across the sidewalk , obstructing the means of egress to the public way at the Northeast Exit.


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

The facility failed to provide proper storage of oxygen cylinders. Findings include: During the survey, the following is an example of what was observed.


Eight unsecured oxygen cylinders in the outside storage area.


1999 NFPA 99, 4-3.1.1.1 and 4-5.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

The facility failed to maintain approved electrical utilities. Findings include: During the survey, the following is an example of what was observed.


1. A junction box was missing the cover in the wash room of the kitchen.


27382


2. D.O.N.'s Office had a refrigerator plugged into a surge protector (extension cord), plugged into another surge protector (extension cord)
3. I.T. (Computer) Room had an electrical junction box missing it's cover plate
4. Patient's Accounts Supervisor's Office had an electrical outlet missing it's cover plate
5. Accounting had a refrigerator plugged into a surge protector (extension cord)

____________

1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.

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.


1999 NFPA 70, 370-28. Pull and Junction Boxes
Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d).
(a) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.