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The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following is an example of what was observed.

The door to ER X-Ray had four holes approximatley the size of a dime around the door handle.
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NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.

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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:

1. Unsealed penetrations at the end of a sleeve, and a hole approximatley the size of a quarter, in the Smoke Barrier, by the elevators Second Floor.

2. Unsealed penetrations around wiring, in the Smoke Barrier, by the Communications Room First Floor.
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2000 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.
2000 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 smoke barrier per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
The smoke barrier in Ultrasound Room 2 (room 1123) had a 2" x 2" unsealed penetration with a gray wire.

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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.
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The facility failed to maintain stairways with at least 1 hour fire resistance rating. During the survey, the following is an example of what was observed:

The latching hardware on the stairwell door by Dietary failed to latch.
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Stairwell opening shall be protected by an approved self-closing fire door. NFPA 101, 19.3.1.2, 8.2.3.2.1, and 7.1.3.2.1(c).

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The facility failed to maintain the two hour fire barrier per code. Findings include:

During the survey, the following is an example of what was observed:
Second Floor
The two hour fire barrier in the Medication Room (room 2100-C) at the Nurses' Station - had an 8" gap from the corridor wall to the column above the lay-in ceiling

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2000 NFPA 101, 8.2.2.2 Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.

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Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the following is an example of what was observed:


When the Auto Dialer was tested for phone line 2, failure was not indicated at the protected premise within the allotted four (4) minute time frame. This surveyor waited (6) minutes failure was never indicated at the panel.
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1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.

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Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the following is an example of what was observed:

When the Auto Dialer was tested for phone line 2, failure was not indicated at the protected premise within the allotted four (4) minute time frame. This surveyor waited (6) minutes failure was never indicated at the panel.

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1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.
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The facility failed to maintain the dietary hood. Findings include: During the survey, the following are examples of what was observed:

One seam was not sealed, and a hole approximatley the size of a quarter was observed above the filters.
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NFPA 96, 2-1.2 Internal hood joints, seams, filter support frames, and appendages attached inside the hood need not be welded but shall be sealed or otherwise made grease tight.
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The facility failed to maintain the med gas alarm panels per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
The Med. Gas Alarm Panel M00100 at the OR Nurses' Station did not give an audible alarm when tested

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1999 NFPA 99, 4-3.1.2.2 Gas Warning Systems. (a) * General. 1. All local, master, and area alarm panels used for medical gas systems shall provide the following: a. Separate visual indicators for each condition monitored b. Cancelable audible indication of an alarm condition. The audible indicator shall produce a minimum of 80 dBA measured at 3 ft (1 m). A second indicated condition occurring while the alarm is silenced shall reinitiate the audible signal c. A means to visually indicate a lamp or LED failure 2. Local, master, and area alarms shall indicate visually and audibly if a. The monitored condition occurs b. The wiring to the sensor or switch is disconnected

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The facility failed to maintain proper emergency lighting at the generator set and controls. Findings include: During the survey, the following is an example of what was observed:

The battery-powered light was inoperable at the generator set and controls.
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1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1. Emergency generator equipment locations.

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The facility failed to maintain proper emergency lighting at the generator set and controls. Findings include: During the survey, the following is an example of what was observed:

The battery-powered light was inoperable at the generator set and controls.
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1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1. Emergency generator equipment locations.

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The facility failed to provide receptacles for appliances. Findings include:During the survey, the following are example of what was observed:

1. The Admitting Manager Office had an overcurrent protection plugged into a overcurrent protection device.

2. Two junction boxes were missing the covers above the ceiling at the Elevators on the Second Floor.
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NFPA 101 Life Safety Code (Sec. 19-5.1) utilities shall comply with NFPA 101 (Sec. 9-1.) . Electrical shall comply with the NFPA 70 National Electrical Code. NEC 400-7(b) Requires each flexible cord to "be energized from a receptacle outlet."

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

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The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following is an example of what was observed.

The door to ER X-Ray had four holes approximatley the size of a dime around the door handle.
----------------------------------
NFPA 101, 19.3.6.3.1 Exception No.2. In the smoke compartments protected throughout by an approved, supervised automatic sprinkler system, doors in corridor walls shall be constructed to resist the passage of smoke and be provided with suitable means of keeping the doors closed.

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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:

1. Unsealed penetrations at the end of a sleeve, and a hole approximatley the size of a quarter, in the Smoke Barrier, by the elevators Second Floor.

2. Unsealed penetrations around wiring, in the Smoke Barrier, by the Communications Room First Floor.
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2000 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.
2000 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 smoke barrier per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
The smoke barrier in Ultrasound Room 2 (room 1123) had a 2" x 2" unsealed penetration with a gray wire.

________________

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.
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The facility failed to maintain stairways with at least 1 hour fire resistance rating. During the survey, the following is an example of what was observed:

The latching hardware on the stairwell door by Dietary failed to latch.
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Stairwell opening shall be protected by an approved self-closing fire door. NFPA 101, 19.3.1.2, 8.2.3.2.1, and 7.1.3.2.1(c).

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The facility failed to maintain the two hour fire barrier per code. Findings include:

During the survey, the following is an example of what was observed:
Second Floor
The two hour fire barrier in the Medication Room (room 2100-C) at the Nurses' Station - had an 8" gap from the corridor wall to the column above the lay-in ceiling

___________________

2000 NFPA 101, 8.2.2.2 Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.

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Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the following is an example of what was observed:


When the Auto Dialer was tested for phone line 2, failure was not indicated at the protected premise within the allotted four (4) minute time frame. This surveyor waited (6) minutes failure was never indicated at the panel.
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1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.

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Facility failed to maintain the Digital Alarm Communicator Transmitter in the fire alarm system. Findings include: During the survey, the following is an example of what was observed:

When the Auto Dialer was tested for phone line 2, failure was not indicated at the protected premise within the allotted four (4) minute time frame. This surveyor waited (6) minutes failure was never indicated at the panel.

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1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line and communication failure shall be indicated at the facility.
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The facility failed to maintain the dietary hood. Findings include: During the survey, the following are examples of what was observed:

One seam was not sealed, and a hole approximatley the size of a quarter was observed above the filters.
---------------------------------------

NFPA 96, 2-1.2 Internal hood joints, seams, filter support frames, and appendages attached inside the hood need not be welded but shall be sealed or otherwise made grease tight.
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The facility failed to maintain the med gas alarm panels per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
The Med. Gas Alarm Panel M00100 at the OR Nurses' Station did not give an audible alarm when tested

___________________

1999 NFPA 99, 4-3.1.2.2 Gas Warning Systems. (a) * General. 1. All local, master, and area alarm panels used for medical gas systems shall provide the following: a. Separate visual indicators for each condition monitored b. Cancelable audible indication of an alarm condition. The audible indicator shall produce a minimum of 80 dBA measured at 3 ft (1 m). A second indicated condition occurring while the alarm is silenced shall reinitiate the audible signal c. A means to visually indicate a lamp or LED failure 2. Local, master, and area alarms shall indicate visually and audibly if a. The monitored condition occurs b. The wiring to the sensor or switch is disconnected

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The facility failed to maintain proper emergency lighting at the generator set and controls. Findings include: During the survey, the following is an example of what was observed:

The battery-powered light was inoperable at the generator set and controls.
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1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1. Emergency generator equipment locations.

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The facility failed to maintain proper emergency lighting at the generator set and controls. Findings include: During the survey, the following is an example of what was observed:

The battery-powered light was inoperable at the generator set and controls.
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1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1. Emergency generator equipment locations.

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The facility failed to provide receptacles for appliances. Findings include:During the survey, the following are example of what was observed:

1. The Admitting Manager Office had an overcurrent protection plugged into a overcurrent protection device.

2. Two junction boxes were missing the covers above the ceiling at the Elevators on the Second Floor.
-------------------------------------

NFPA 101 Life Safety Code (Sec. 19-5.1) utilities shall comply with NFPA 101 (Sec. 9-1.) . Electrical shall comply with the NFPA 70 National Electrical Code. NEC 400-7(b) Requires each flexible cord to "be energized from a receptacle outlet."

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

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