HospitalInspections.org

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The facility failed to maintain the vertical opening per code. Findings include:

During the survey, the following is an example of what was observed:
Electrical Room F14 had a 3" unsealed conduit with wires penetrating the ceiling/floor assembly
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2000 NFPA 101, 19.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.
2000 NFPA 101, 8.2.5.1 Every floor that separates stories in a building shall be constructed as a smoke barrier to provide a basic degree of compartmentation. (See 3.3.182 for definition of Smoke Barrier.)
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The facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating. Findings include:
During the survey, the following is an example of what was observed:

1. Unsealed penetrations around a section of flex conduit, and a sprinkler line, in the Smoke Barrier by the entrance to "D" Ward Second Floor.
2. Unsealed penetrations around conduit in the Smoke Barrier by DD-13 Social Workers Office Second Floor.


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3. The smoke barrier at XY21 had an unsealed penetration of a group of wires
4. The smoke barrier at C Ward Entrance had:
a. An unsealed penetration on the top of an automatic sprinkler pipe (left of the door)
b. An unsealed penetration of a black wire (right of the door)
5. The smoke barrier at room C25 had two unsealed 2 1/2" holes, one hole had two wires penetrating the smoke barrier
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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 the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:
The following storage rooms were over 50 sq. ft., with combustibles - the doors did not have self-closing devices:
1. P18
2. P19
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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.

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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 located by Ward "E" was not provided with an all weather surface to the public way.
2. The Exit located by Ward "F" was not provided with an all weather surface to the public way.
3. The Exit located by Ward "F"-36 was not provided with an all weather surface to the public way.


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4. Per observation and interview the corridor door to the Quiet Room/Timeout Room at the Nurses' Station on C Ward did have a device to insure the door was positive latching, but did not have a device to release the positive latching device (to allow egress from this room)on the control/corridor side of the door
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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.
NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.
2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
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.
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The facility failed to provide proper emergency lighting: Findings include: During the survey, the following is an example of what was observed:

The maintenance director was not able to verify if the exit discharge lighting was on the generators.
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NFPA 101, 7.9.2.3 Emergency generators providing power to emergency lighting systems to be installed per NFPA 110.

7.9.1.1* Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply
For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.

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

During the survey, the following is an example of what was observed:
Per documentation from the facility the fire safety plan did not contain all eight items per code, an example is smoke compartment evacuation

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

During the survey, the following are examples of what was observed:
1. The facility failed to provide proof of participation of all on duty staff at the time of the fire drills
2. The following are the documented fire drills provided by the facility at the time of the survey:
First Shift
04/09/2013 - 11:00 am
NO DRILL
10/01/2012 - 11:00 am
NO DRILL

Second Shift
04/07/2013 - 6:00 pm
03/01/2013 - 7:05 pm
11/05/2013 - 5:00 pm
NO DRILL

Third Shift
05/04/2013 - 5:30 am
NO DRILL
12/10/2012 - 6:00 am
NO DRILL

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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.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.
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The facility failed to maintain the fire alarm system in proper working order. Findings include: During the survey, the following is an example of what was observed:

Ward "A" for the Deaf the corridors and dayrooms had audible fire alarm devices only.


2000 NFPA 101, 9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this code.

2000 NFPA 101, 9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3. through 9.6.3.12.


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2. "A" Ward for the Deaf the corridors and dayrooms had audible fire alarm devices only
3. Per observation and interview the fire alarm panel had only one phone line
4. The facility and supervising station only received a general trouble when the phone line was disconnected
5. The fire alarm strobe at Hall XX30 was not flashing when the fire alarm system was tested

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2000 NFPA 101, 9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.

2000 NFPA 101, 9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.

1999 NFPA 72, 4-4.4.2.1 Table 4-4.4.2.1 shall apply to corridors not exceeding 20 ft (6.1 m) in width. For corridors greater than 20 ft (6.1 m) wide, Figure 4-4.4.1.1 and Tables 4-4.4.1.1(a) and (b) shall apply. In a corridor application, visible appliances shall be rated not less than 15 cd.

1999 NFPA 72, 4-4.4.2.2* Visible notification appliances shall be located not more than 15 ft (4.57 m) from the end of the corridor with a separation not greater than 100 ft (30.4 m) between appliances. If there is an interruption of the concentrated viewing path, such as a fire door, an elevation change, or any other obstruction, the area shall be treated as a separate corridor.

1999 NFPA 72, 5-2.4.4* Two independent means shall be provided to retransmit a fire alarm signal to the designated public fire service communications center.

1999 NFPA 72, 5-3.6.1.2 If a communications or transmission channel fails to operate, the operator shall immediately notify the person(s) identified by the owner or authority having jurisdiction.

2000 NFPA 101, 19.3.4.3.1 Occupant notification shall be accomplished automatically in accordance with 9.6.3.
2000 NFPA 101, 9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.
2000 NFPA 101, 9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
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Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following are examples of what was observed.

1. The fire department connection did not have an identification sign.
2. Documentation was not provided for the five year replacement of the riser gauges.
3. The escutcheon plate was hanging loose around the deflector of a sprinkler at Admitting Entrance.
4. Recessed sprinkler missing the cover in the TV Room "F" Ward.
5. Recessed sprinkler missing the cover in D-20 exam room.
6. Recessed sprinkler missing the cover in D-12 seclusion room.
7. The escutcheon plate loose on a sprinkler in room B-26.


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8. The following rooms were observed with recessed automatic sprinkler heads cover plates with sheetrock mud on them, possibly preventing the automatic sprinkler heads from activating:
a. F10 Soiled Linen
b. F19 Clean Linen
c. F40
9. The recessed automatic sprinkler head in room C36 Toilet was missing the cover plate
10. The automatic sprinkler pipe in room A16 was observed with a group of wires attached to the pipe

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

NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following: (a) The fire department connections are visible and accessible. (b) Couplings or swivels are not damaged and rotate smoothly. (c) Plugs or caps are in place and undamaged. (d) Gaskets are in place and in good condition. (e) Identification signs are in place. (f) The check valve is not leaking. (g) The automatic drain valve is in place and operating properly.

NFPA 25, Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance

NFPA 25, 9-2.8.2: Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

NFPA 25, 9-2.8.1: Gauges shall be inspected monthly to verify that they are in good condition and that normal pressure is being maintained. Exception: When other sections of this standard have different frequency requirements for specific gauges.

2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

1998 NFPA 25, 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
1998 NFPA 25, 2-4.1.8 Sprinklers shall not be altered in any respect or have any type of ornamentation, paint, or coatings applied after shipment from the place of manufacture.
1999 NFPA 13, 6-1.1.5* Sprinkler piping or hangers shall not be used to support nonsystem components.
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The facility failed to prohibit the use of a portable space-heating device per code. Findings include:

During the survey, the following are examples of what was observed:
The following rooms had portable space-heating devices, some were observed in sleeping areas, others were observed in nonsleeping staff and employee areas, the facility failed to provide documentation that the heating elements of such devices did not exceed 212?F (100?C):
1. FF9 Head Nurse's Office
2. XY11
3. Charge Nurse's Office for C Ward had two (one was plugged in)
4. P28
5. P5

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2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212?F (100?C).
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The facility failed to meet the requirements for the above ground fuel storage tanks. Findings include: During the survey, the following is an example of what was observed:

The diesel above ground storage tank did not have signage to identified the fire hazard of product,or no smoking sign. This tank supplies fuel for the generator.
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NFPA 30 2-9.3, Unsupervised, isolated aboveground tanks shall be secured and marked in such a manner as to identify the fire hazards of the tank and its contents to the general public. The area in which the tank is located shall be protected from tampering or trespassing, where necessary.

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The facility failed to maintain the emergency generator per code. Findings include:

During the survey, the following is an example of what was observed:
Per interview and documentation the facility was not conducting weekly inspections on the emergency generator

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1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
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The facility failed to provide an emergency generator per code. Findings include:

During the survey, the following are examples of what was observed:
1. The facility failed to provide a remote annunciator for the emergency generator
2. Per documentation from the facility inspection reports for the emergency generator in 09/2012 and in 10/2010 recommended replacing the battery, the facility failed to provide documentation that this condition had been corrected

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1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows: (a) Individual visual signals shall indicate the following: 1. When the emergency or auxiliary power source is operating to supply power to load 2. When the battery charger is malfunctioning (b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following: 1. Low lubricating oil pressure 2. Low water temperature (below those required in 3-4.1.1.9) 3. Excessive water temperature 4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply 5. Overcrank (failed to start) 6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]
1999 NFPA 99, 3-6.4.2 A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.
1999 NFPA 99, 3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches. (a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
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The facility failed to maintain approved electrical utilities. Findings include: During the survey, the following are examples of what was observed:

1. Junction box was missing the cover in Room EE-11.
2. Refrigerator was plugged into a circuit breaker protected power strip in Office R-17.
3. Refrigerator was plugged into a circuit breaker protected power strip in Office R-16.


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4. The following rooms were observed with extension cords, refrigerators and/or microwaves plugged into surge protectors (extension cords), and extension cords and/or surge protectors (extension cords) plugged into extension cords and/or surge protectors (extension cords):
a. FF10
b. FF9
c. FF8
e. FF13
f. F15
g. F43
h. XX28
i. XX14
j. XX10
k. XX9
l. XY10
m. C43
n. CC6
o. Charge Nurse's Office for C Ward
p. P28
q. P9

5. Two electrical junction boxes were observed without cover plates above the ceiling HVAC diffuser at room CC2

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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, 400-7 (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.

1999 NFPA 70, 370-25. Covers and Canopies In completed installations, each box shall have a cover, faceplate, or fixture canopy.
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The facility failed to provide a complete fire watch procedure per code. Findings include:

During the survey, the following is an example of what was observed:
The fire watch provided by the facility was incomplete

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2000 NFPA 101, 9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.
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The facility failed to provide a complete fire watch procedure per code. Findings include:

During the survey, the following is an example of what was observed:
The fire watch provided by the facility was incomplete

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2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
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The facility failed to maintain the vertical opening per code. Findings include:

During the survey, the following is an example of what was observed:
Electrical Room F14 had a 3" unsealed conduit with wires penetrating the ceiling/floor assembly
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2000 NFPA 101, 19.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.
2000 NFPA 101, 8.2.5.1 Every floor that separates stories in a building shall be constructed as a smoke barrier to provide a basic degree of compartmentation. (See 3.3.182 for definition of Smoke Barrier.)
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The facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating. Findings include:
During the survey, the following is an example of what was observed:

1. Unsealed penetrations around a section of flex conduit, and a sprinkler line, in the Smoke Barrier by the entrance to "D" Ward Second Floor.
2. Unsealed penetrations around conduit in the Smoke Barrier by DD-13 Social Workers Office Second Floor.


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3. The smoke barrier at XY21 had an unsealed penetration of a group of wires
4. The smoke barrier at C Ward Entrance had:
a. An unsealed penetration on the top of an automatic sprinkler pipe (left of the door)
b. An unsealed penetration of a black wire (right of the door)
5. The smoke barrier at room C25 had two unsealed 2 1/2" holes, one hole had two wires penetrating the smoke barrier
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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 the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:
The following storage rooms were over 50 sq. ft., with combustibles - the doors did not have self-closing devices:
1. P18
2. P19
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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.

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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 located by Ward "E" was not provided with an all weather surface to the public way.
2. The Exit located by Ward "F" was not provided with an all weather surface to the public way.
3. The Exit located by Ward "F"-36 was not provided with an all weather surface to the public way.


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4. Per observation and interview the corridor door to the Quiet Room/Timeout Room at the Nurses' Station on C Ward did have a device to insure the door was positive latching, but did not have a device to release the positive latching device (to allow egress from this room)on the control/corridor side of the door
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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.
NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.
2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
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.
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The facility failed to provide proper emergency lighting: Findings include: During the survey, the following is an example of what was observed:

The maintenance director was not able to verify if the exit discharge lighting was on the generators.
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NFPA 101, 7.9.2.3 Emergency generators providing power to emergency lighting systems to be installed per NFPA 110.

7.9.1.1* Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply
For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.

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

During the survey, the following is an example of what was observed:
Per documentation from the facility the fire safety plan did not contain all eight items per code, an example is smoke compartment evacuation

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

During the survey, the following are examples of what was observed:
1. The facility failed to provide proof of participation of all on duty staff at the time of the fire drills
2. The following are the documented fire drills provided by the facility at the time of the survey:
First Shift
04/09/2013 - 11:00 am
NO DRILL
10/01/2012 - 11:00 am
NO DRILL

Second Shift
04/07/2013 - 6:00 pm
03/01/2013 - 7:05 pm
11/05/2013 - 5:00 pm
NO DRILL

Third Shift
05/04/2013 - 5:30 am
NO DRILL
12/10/2012 - 6:00 am
NO DRILL

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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.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.
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The facility failed to maintain the fire alarm system in proper working order. Findings include: During the survey, the following is an example of what was observed:

Ward "A" for the Deaf the corridors and dayrooms had audible fire alarm devices only.


2000 NFPA 101, 9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this code.

2000 NFPA 101, 9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3. through 9.6.3.12.


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2. "A" Ward for the Deaf the corridors and dayrooms had audible fire alarm devices only
3. Per observation and interview the fire alarm panel had only one phone line
4. The facility and supervising station only received a general trouble when the phone line was disconnected
5. The fire alarm strobe at Hall XX30 was not flashing when the fire alarm system was tested

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2000 NFPA 101, 9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.

2000 NFPA 101, 9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.

1999 NFPA 72, 4-4.4.2.1 Table 4-4.4.2.1 shall apply to corridors not exceeding 20 ft (6.1 m) in width. For corridors greater than 20 ft (6.1 m) wide, Figure 4-4.4.1.1 and Tables 4-4.4.1.1(a) and (b) shall apply. In a corridor application, visible appliances shall be rated not less than 15 cd.

1999 NFPA 72, 4-4.4.2.2* Visible notification appliances shall be located not more than 15 ft (4.57 m) from the end of the corridor with a separation not greater than 100 ft (30.4 m) between appliances. If there is an interruption of the concentrated viewing path, such as a fire door, an elevation change, or any other obstruction, the area shall be treated as a separate corridor.

1999 NFPA 72, 5-2.4.4* Two independent means shall be provided to retransmit a fire alarm signal to the designated public fire service communications center.

1999 NFPA 72, 5-3.6.1.2 If a communications or transmission channel fails to operate, the operator shall immediately notify the person(s) identified by the owner or authority having jurisdiction.

2000 NFPA 101, 19.3.4.3.1 Occupant notification shall be accomplished automatically in accordance with 9.6.3.
2000 NFPA 101, 9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.
2000 NFPA 101, 9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
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Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following are examples of what was observed.

1. The fire department connection did not have an identification sign.
2. Documentation was not provided for the five year replacement of the riser gauges.
3. The escutcheon plate was hanging loose around the deflector of a sprinkler at Admitting Entrance.
4. Recessed sprinkler missing the cover in the TV Room "F" Ward.
5. Recessed sprinkler missing the cover in D-20 exam room.
6. Recessed sprinkler missing the cover in D-12 seclusion room.
7. The escutcheon plate loose on a sprinkler in room B-26.


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8. The following rooms were observed with recessed automatic sprinkler heads cover plates with sheetrock mud on them, possibly preventing the automatic sprinkler heads from activating:
a. F10 Soiled Linen
b. F19 Clean Linen
c. F40
9. The recessed automatic sprinkler head in room C36 Toilet was missing the cover plate
10. The automatic sprinkler pipe in room A16 was observed with a group of wires attached to the pipe

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

NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following: (a) The fire department connections are visible and accessible. (b) Couplings or swivels are not damaged and rotate smoothly. (c) Plugs or caps are in place and undamaged. (d) Gaskets are in place and in good condition. (e) Identification signs are in place. (f) The check valve is not leaking. (g) The automatic drain valve is in place and operating properly.

NFPA 25, Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance

NFPA 25, 9-2.8.2: Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

NFPA 25, 9-2.8.1: Gauges shall be inspected monthly to verify that they are in good condition and that normal pressure is being maintained. Exception: When other sections of this standard have different frequency requirements for specific gauges.

2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

1998 NFPA 25, 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
1998 NFPA 25, 2-4.1.8 Sprinklers shall not be altered in any respect or have any type of ornamentation, paint, or coatings applied after shipment from the place of manufacture.
1999 NFPA 13, 6-1.1.5* Sprinkler piping or hangers shall not be used to support nonsystem components.
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The facility failed to prohibit the use of a portable space-heating device per code. Findings include:

During the survey, the following are examples of what was observed:
The following rooms had portable space-heating devices, some were observed in sleeping areas, others were observed in nonsleeping staff and employee areas, the facility failed to provide documentation that the heating elements of such devices did not exceed 212?F (100?C):
1. FF9 Head Nurse's Office
2. XY11
3. Charge Nurse's Office for C Ward had two (one was plugged in)
4. P28
5. P5

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2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212?F (100?C).
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The facility failed to meet the requirements for the above ground fuel storage tanks. Findings include: During the survey, the following is an example of what was observed:

The diesel above ground storage tank did not have signage to identified the fire hazard of product,or no smoking sign. This tank supplies fuel for the generator.
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NFPA 30 2-9.3, Unsupervised, isolated aboveground tanks shall be secured and marked in such a manner as to identify the fire hazards of the tank and its contents to the general public. The area in which the tank is located shall be protected from tampering or trespassing, where necessary.

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The facility failed to maintain the emergency generator per code. Findings include:

During the survey, the following is an example of what was observed:
Per interview and documentation the facility was not conducting weekly inspections on the emergency generator

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1999 NFPA 110, 6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
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The facility failed to provide an emergency generator per code. Findings include:

During the survey, the following are examples of what was observed:
1. The facility failed to provide a remote annunciator for the emergency generator
2. Per documentation from the facility inspection reports for the emergency generator in 09/2012 and in 10/2010 recommended replacing the battery, the facility failed to provide documentation that this condition had been corrected

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1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.) The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows: (a) Individual visual signals shall indicate the following: 1. When the emergency or auxiliary power source is operating to supply power to load 2. When the battery charger is malfunctioning (b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following: 1. Low lubricating oil pressure 2. Low water temperature (below those required in 3-4.1.1.9) 3. Excessive water temperature 4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply 5. Overcrank (failed to start) 6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]
1999 NFPA 99, 3-6.4.2 A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.
1999 NFPA 99, 3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches. (a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
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The facility failed to maintain approved electrical utilities. Findings include: During the survey, the following are examples of what was observed:

1. Junction box was missing the cover in Room EE-11.
2. Refrigerator was plugged into a circuit breaker protected power strip in Office R-17.
3. Refrigerator was plugged into a circuit breaker protected power strip in Office R-16.


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4. The following rooms were observed with extension cords, refrigerators and/or microwaves plugged into surge protectors (extension cords), and extension cords and/or surge protectors (extension cords) plugged into extension cords and/or surge protectors (extension cords):
a. FF10
b. FF9
c. FF8
e. FF13
f. F15
g. F43
h. XX28
i. XX14
j. XX10
k. XX9
l. XY10
m. C43
n. CC6
o. Charge Nurse's Office for C Ward
p. P28
q. P9

5. Two electrical junction boxes were observed without cover plates above the ceiling HVAC diffuser at room CC2

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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, 400-7 (b) Attachment Plugs. Where used as permitted in subsections (a)(3), (a)(6), and (a)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet.

1999 NFPA 70, 370-25. Covers and Canopies In completed installations, each box shall have a cover, faceplate, or fixture canopy.
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The facility failed to provide a complete fire watch procedure per code. Findings include:

During the survey, the following is an example of what was observed:
The fire watch provided by the facility was incomplete

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2000 NFPA 101, 9.7.6.1 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.
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The facility failed to provide a complete fire watch procedure per code. Findings include:

During the survey, the following is an example of what was observed:
The fire watch provided by the facility was incomplete

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2000 NFPA 101, 9.6.1.8 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
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