HospitalInspections.org

K-11: While surveying the facility with the facility maintenance manager the inspector observed penetrations through the fire-resistive wall serving as separation from the adjacent non-conforming construction in the " Tel-Com " room off the Central Sterile space. Two conduits passing through the fire-rated wall assembly were found where the fire stopping material had fallen free of the conduits.

K-12: While surveying the facility with the facility maintenance manager the inspector observed an unprotected structural steel beam present in the electrical room on the ground floor of the building (Facility room designation G-023B). The unprotected span of the beam observed was approximately 16 feet. Adjacent columns appeared to be protected utilizing a drywall rating system. A minimum of Type II(111) construction is required pursuant to the standard.

K 17 Not Met.

While conducting the walk-through inspection, this inspector observed, in the presents of the plant engineer, that the corridor wall above the drop ceiling at the door location A 2-2, was not sealed to prevent the passage of smoke from the corridor to the use space behind the door.

K-018 Not Met.
While surveying the facility with the safety officer this inspector observed the doors located at F1-103 (ER) have a gap between the doors and are not smoke resistant as required.

K 20 Not Met.

1) During the walk-through inspection, this inspector observed in the presents of the facility maintenance officer, the linen chute in room designated C-2, failed to always close and latch completely. This allows for a unprotected vertical opening between multiple floors and fails to maintain the required one hour separation.

2) During the walk-through inspection, this inspector observed in the presents of the facility maintenance manager, holes above the drop ceiling tiles that penetrated the elevator shaft at the location marked AB-1. This allows for a unprotected vertical opening between multiple floors and fails to maintain the required one hour separation.

3) During the walk-through inspection, this inspector observed in the presents of the facility plant engineer, that the shaft across from room B 201, above the drop ceiling tiles, the duct inside the shaft had not been properly sealed to maintain the required one-hour fire separation.

4) During the walk-through inspection, this inspector observed in the presents of the facility plant engineer, that non rated "pink insulation" material had been used to seal a penetration around where a conduit passed through the wall into a elevator shaft at the door location marked C-478.

5) During the walk-through inspection, this inspector observed in the presents of the facility plant engineer, penetrations above the drop ceiling tiles entering the elevator shaft for elevator 6, 4th floor, D area.

6) During the walk-through inspection, this inspector observed in the presents of the facility maintenance manager, penetration in the Electrical closet that appeared to enter the elevator shaft in the location where the door is marked 3-C.

K-025 Not Met.
1) While surveying the facility with the safety officer this inspector observed that the fire/smoke barrier above the doors located at C1-3 has several penetrations that were not sealed as required.

2) This inspector observed in the presents of the plant engineer that holes were located above the drop ceiling tiles located above door B4-3. This wall is required to be at least one-hour fire rated and had penetrations through it which were not fully sealed.

3) This inspector observed in the presents of the plant engineer that holes were located above the drop ceiling tiles located above the door marked D3-1. This wall is required to be at least one-hour fire rated and had missing gypsum wallboard and holes that were not fully sealed.

4) This inspector observed in the presents of the plant engineer that holes were located above the drop ceiling tiles located above the double doors mark G 0-5. This wall is required to be at least one-hour fire rated.

5) This inspector observed in the presents of the plant engineer that holes were located above the drop ceiling located in room with the door marked G-027. This wall is required to be at least one-hour fire rated.

6) This inspector observed in the presents of the plant engineer holes from the Electrical room to the corridor outside. This was noted in the room with the door marked C 044. This wall is required to be at least one-hour fire rated.

7) This inspector observed in the presents of the plant engineer holes in one of the main Electrical rooms (door marked G 037) to the corridor outside. This wall is required to be at least one-hour fire rated.

8) This inspector observed in the presents of the plant engineer, penetrations above the drop ceiling, at the door location marked WSH 2-B. The penetrations appeared to have been filled with fire rated mineral wool batting but had not been sealed over with a fire rated sealant to form the required listed fire rated assembly, in order to maintain the required one-hour fire rating.

9) This inspector observed, in the presents of the plant engineer, above the drop ceiling tiles, the penetration of the sprinkler piping, had not been properly sealed to maintain the required one-hour fire rating at the cross corridor door marked D-042.

K- 27 not met.
1) This inspector observed in the presents of the plant engineer that the cross corridor doors outside the Outpatient Nurses's station did not meet the requirement of having at least a 20 minute fire protection rating. The doors had labels which specifically stated they were "unable to be labeled".

2) While surveying the facility with the safety officer this inspector observed the double doors labeled AB 3-4 have a gap between the meeting edges of the doors greater then the allowed 1/8" plus or minus a 1/16" as required by NFPA 80 Standard for Fire Doors and Other Opening Protectives.

3) While surveying the facility with the safety officer this inspector observed the double doors labeled AB 1-5 have a gap between the meeting edges of the two doors greater then the allowed 1/8" plus or minus 1/16" as required by NFPA 80 Standard for Fire Doors and Other Opening Protectives.

K-29 not met:
1) While surveying the facility with the facility maintenance manager the inspector observed that the fire rated door assembly opening from the Pathology lab into the lab corridor space had been secured in the open position utilizing a wooden wedge in violation of the standard. The wedge was removed at the time of the discovery and the maintenance manager verbally informed staff present at the time of the inspection that the practice of wedging fire doors open was prohibited.

2) While surveying the facility with the safety officer this inspector observed that the door on the soiled utility room located at F1-103 did not latch as required.

3) During the survey of the facility this inspector in the presents of the plant engineer observed a large passageway from the boiler room to the void space above the operating rooms which had not been sealed as required to maintain the required one hour fire rated separation. This passage way allowed various conduits and pipes to feed other locations of the hospital.

4) While surveying the facility, this inspector observed that the door and the door frame into the soiled laundry room (door marked A-345) did not meet the requirements listed under NFPA 80, Standard for Fire Doors and Other Opening Protectives, for a 3/4 hour fire rated door, due to unfilled holes in the doorframe and missing screws in the hinges.

K-30: While surveying the facility with the facility maintenance manager the inspector observed that the gift shop storage area lacked smoke resistive separation between the storage area and the gift shop sales area. The door opening between the gift shop storage area and the sales area must be provided with a self-closing and positively latching door assembly that is capable of resisting the passage of smoke in accordance with NFPA 101 Life Safety Code sections 19.3.2.1, 19.3.2.5, 8.3, and 8.4 (2000 edition).

K-33:
1) While surveying the facility with the facility maintenance manager the inspector observed that one of the doors opening into an egress stairwell on the ground floor failed to meet the required one-hour fire resistance rating required by the standard. (Facility door designation H0045). The 90 minute rated fire door assembly was found to have a vision panel rated to only a 45 minute fire-resistive rating according to the markings present on the door glazing at the time of the inspection.

2) While surveying the facility with the facility maintenance manager, this inspector observed holes existing above the drop ceiling tiles, which penetrated into the stair enclosure at the D3-1 FD door location.

3) While surveying the facility with the facility maintenance manager this inspector observed holes existing above the drop ceiling tiles, (which had been filed with Pink Insulation material), which penetrated into the stair enclosure at the D3-2 FD door location.

4) While surveying the facility with the facility maintenance manager this inspector observed holes existing above the drop ceiling tiles, which penetrated into the stair enclosure at the D 2-1 FD door location.

5) During the walk-through inspection, this inspector observed in the presents of the facility plant engineer, above the drop ceiling tiles, penetrations into the stair enclosure at the door location marked A237. In several of these locations it appeared Duct Tape had been used to seal the holes and where wall joints came together.

6) During the walk-through inspection, this inspector observed in the presents of the facility plant engineer, above the drop ceiling tiles (door marked WS 2-2), that the walls had not been properly sealed to the floor pan above. Fire rated mineral wool batting appears to have been installed but was not sealed over with a fire rated sealant to form the required listed fire rated assembly, in order to maintain the required one-hour fire rated enclosure.

K 38 not met.
During the walk-through inspection, this inspector observed in the presents of the plant engineer, a section of corridor (approx. 56 ft. 6 in.) in the A & B first floor level 1 wing which did not provide the proper head height as required (84"). When measured the ceiling height was between 76 1/4" and 77". Within this section of corridor, 5 doors were also observed entering into normally occupied spaces, which did not provide the proper head height as required for doors (80"). When measured these door provided 77" for a clear opening in height.

K-39: While surveying the facility with the facility maintenance manager the inspector observed that the corridor space outside the gift shop was reduced in clear width to approximately 6 feet due to the merchandising of sales items in the corridor space. The required clear width of the corridor in accordance with the standard is not less than 8 feet.

K 56 Not Met.

During the walk-through inspection of the facility, in the presents of the facility safety officer a large storage room was found which had not been protected by the installed sprinkler system as required under NFPA 13 in two locations. One location was B 200 and the other location was B 300 which sits directly above the first location cited.

K-130 offsite facility office buildings surveyed under NFPA Life Safety Code 101, 2009 Edition.


1. No records for the operation and maintenance of any of the off-site facilities emergency systems were available at the various locations for review.

2. No records demonstrating testing of the exits signs specifically could be shown by the facility for any off-site location. Currently "Emergency Lights" and "Exits Signs" are grouped under one category listed as Emergency Lighting.

100 Campus Avenue, Lewiston: Breast Health
1. Ceiling height in the Breast Health Suite was found to measure 6 feet and 6.5 inches above the finished floor level in access hallway within the suite space. In other locations the ceiling height was found to measure approximately 7 feet and 3 inches in height.
NOT MET: NFPA 101 Life Safety Code (2009 edition) Section 7.5.1: In existing buildings, the ceiling height shall be not less than 7 ft (2135 mm) from the floor, with projections from the ceiling not less than 6 ft 8 in. (2030 mm) nominal above the floor.

2. Penetrations were observed in the elevator machinery room wall located in the Breast Health suite. Damage to the rated wall assembly was observed above the door and a gap of approximately ? inch was observed around ducts penetrating the wall.
NOT MET: NFPA 101 Life Safety Code (2009 edition), Sections 39.3.2 and 8.7

3. Additional spare fire sprinkler heads must be provided. Each type of fire sprinkler present in the protected facility must have a stocked replacement heads present.
At the time of the inspection an insufficient quantities and types of spare fire sprinkler heads were present in the spare supply box for the system.
NOT MET: NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (2008 edition), Section 5.2.1.3

963 Sabattus Street, Lewiston: Sabattus Primary Care
1. Several locking or latching devices were observed on required exterior egress doors. Not more than one releasing operation is permitted to open a door in the required means of egress.
NOT MET: NFPA 101 Life Safety Code (2009 edition) Section 7.2.1.5.9.2: The releasing mechanism shall open the door leaf with not more than one releasing operation, unless otherwise specified in 7.2.1.5.9.3 and 7.2.1.5.9.4. Section 7.2.1.5.9.3 and 7.2.1.5.9.4 apply to residential locking arrangements.

3 Willow Run, Auburn: L-A Internal Medicine
1. The egress stairwell door at the basement level of the building must fully close and latch in the closed position. At the time of the inspection the door would not fully close or latch with the force applied by the self-closing device on the door.
NOT MET: NFPA 101 Life Safety Code (2009 edition) Sections 39.3.1, 8.6, and 7.1.3.2.1

2. The required means of egress discharging directly at grade from the basement level of the building is arranged so that occupants must pass through the basement storage area to access the exit. Access to a required means of egress cannot be through an area defined as a hazardous area.
NOT MET: NFPA 101 Life Safety Code (2009 edition) Section 7.5.1.6: Exit access from rooms or spaces shall be permitted to be through adjoining or intervening rooms or areas, provided that such rooms or areas are accessory to the area served. Foyers, lobbies, and reception rooms constructed as required for corridors shall not be construed as intervening rooms. Exit access shall be arranged so that it is not necessary to pass through any area identified under Protection from Hazards in Chapters 11 through 43.

3. The basement heating and storage area lacks the required one hour fire-resistive hazard area separation from the remainder of the building. The wall partitions separating the area from the remainder of the building are not continuous to the ceiling assembly above the space. The ceiling assembly also does not meet the requirement of a one hour fire-resistive assembly as it was observed at the time of the inspection to be exposed OSB/plywood. The heating and storage space contained paper file storage, air handling equipment, and a fuel fired heating device at the time of inspection.
NOT MET: NFPA 101 Life Safety Code (2009 edition) Sections 39.3.2.1 and 8.7: Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.7.

4. More than one latching/locking device was observed on some of the exterior exit doors for the practice. Panic exit hardware and turn-style deadbolt devices were in use simultaneously on exterior doors in the required means of egress. Not more than one releasing operation is permitted to open a door in the required means of egress.
NOT MET: NFPA 101 Life Safety Code (2009 edition) Section 7.2.1.5.9.2: The releasing mechanism shall open the door leaf with not more than one releasing operation, unless otherwise specified in 7.2.1.5.9.3 and 7.2.1.5.9.4. Section 7.2.1.5.9.3 and 7.2.1.5.9.4 apply to residential locking arrangements.

5. A round, graspable handrail must be provided at both sides of the exterior rear exit stair serving the exit door adjacent to the stairwell to the basement level
NOT MET: NFPA 101 Life Safety Code (2009 edition) Section 7.2.2.4.1

60 Second Street, Auburn: Second Street Family Practice
1. At the time of the inspection exit access to the exit door from the staff reception area was observed to be restricted to approximately 27 inches in clear width. Storage of a drinking water dispenser, photocopiers, and supplies obstructed the available clear exit access width.
NOT MET: NFPA 101 Life Safety Code (2009 edition) Sections 7.3.4 and 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.
7.3.4.1 The width of any means of egress, unless otherwise provided in 7.3.4.1.1 through 7.3.4.1.3, shall be as follows:
(1) Not less than that required for a given egress component in this chapter or Chapters 11 through 43
(2) Not less than 36 in. (915 mm)

2. A round, graspable handrail must be provided at both sides of the exit steps adjacent to the billing office.
NOT MET: NFPA 101 Life Safety Code (2009 edition) Section 7.2.2.4.1

3. Hazard signage in accordance with NFPA 704 Standard System for the
Identification of the Hazards of Materials for Emergency Response must be placed on the container -and- at the entrance of the room or space where the liquid nitrogen is used. At the time of the inspection one Dewar Flask of liquid nitrogen with a liquid capacity of approximately 35 liters was observed in the procedure room. While warning signage was present at the time of the inspection, no NFPA 704 compliant hazard identification system warnings were observed to be present.
NOT MET: NFPA 55 Standard for the Storage, Use, and Handling of Compressed Gases and Cryogenic Fluids in Portable and Stationary Containers, Cylinders, and Tanks (2005 edition) Section 8.4.1.3: Identification Signs. Visible hazard identification signs shall be provided in accordance with NFPA 704, Standard System for the Identification of the Hazards of Materials for Emergency Response, at entrances to buildings or areas in which cryogenic fluids are stored, handled, or used.

4. Noted on the latest sprinkler system inspection report, insufficient sprinkler system coverage was found in the computer room and needs to be corrected. (noted 1/12/12 report)

1230 Maine Street, Poland: Poland Family Practice
1. Oxygen supply room was not identified with warning signs as required ( NFPA 99).

2. The stairs to basement were not provided with approved guards.

3. The boiler room is not separated from the basement area with the required 1 hour fire
rated walls and door.

Two Great Falls Plaza, Auburn: St Mary ' s Orthopedics (2nd floor office suite)
1. The office space was not provided with approved oxygen warning signs (NFPA 99)

2. No spare sprinkler heads were noted on the latest documentation available for review of the sprinkler system inspection reports. (noted 9/21/11)

3. The facility was unable to provide documentation which demonstrated the fire alarm system was being maintained in accordance with NFPA 72 National Fire Alarm Code.

583 Lisbon Road, Lisbon Falls: Lisbon Falls Healthcare
1. Exit door eastside of building would not open without forcing the door.

2. Oxygen supply room was not provided with approved warning signs (NFPA 99)

3. Reviewing the sprinkler system inspection reports the last 2 reports noted corrosion on certain sprinkler heads, which need to be replaced. (NFPA 13 & 25)

4. Reviewing the building fire alarm system inspection reports, the last 2 reports (dated 3/2011 & 1/5/12) have noted on-going deficiencies, which have not been properly addressed or corrected. (NFPA 72)

106 Campus Ave. Lewiston: Lewiston Medical Associates
1. Emergency lights located in the hallway of the practice not working
NOT MET : NFPA 101 Life Safety Code (2009 Edition) 4.5.8 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained, unless the Code exempts such maintenance.

2. Several fire rated doors within the exit enclosure were being held open at the time of inspection
NOT MET : NFPA 101 Life Safety Code (2009 edition) 7.2.1.8.1* A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3.

3. All Exterior doors shall have a level landing on both sides of the door
NOT MET: NFPA 101 Life safety Code (2009 Edition) 7.2.1.3.1 The elevation of the floor surfaces on both sides of a door opening shall not vary by more than ? in. (13 mm), unless otherwise permitted by 7.2.1.3.5 or 7.2.1.3.6. 7.2.1.3.2 The elevation of the floor surfaces required by 7.2.1.3.1 shall be maintained on both sides of the door openings for a distance not less than the width of the widest leaf.

4. Provide an exit sign at the main entrance to the building
NOT MET : NFPA 101 Life Safety Code 101 (2009 Edition) 39.2.10 Marking of Means of Egress. Means of egress shall have signs in accordance with Section 7.10.

99 Campus Ave, Lewiston:
4 story business office occupancy

1. The emergency light within the first floor electrical room was not working at the time of inspection.
NOT MET: NFPA 101 Life Safety Code(2009 Edition)
39.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

2. Multiple penetrations within the 2 hour fire separation between the hospital occupancy and the business occupancy were observed above the ceiling tile .
NOT MET: NFPA 101 Life Safety Code (2009 Edition)
19.1.1.4.1 Additions. Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition.

3. Exit sign on the exterior door within the connector was not illuminated at the time of the inspection.
NOT MET: NFPA 101 Life Safety Code (2009 Edition)
39.2.10 Marking of Means of Egress. Means of egress shall have signs in accordance with Section 7.10.

4. The west stair enclosure at the first floor has multiple penetrations through the rated enclosure.
NOT MET : NFPA 101 Life Safety Code (2009 Edition)
7.1.3.2.1 Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following:
(1)* The separation shall have a minimum 1-hour fire resistance rating where the exit connects three or fewer stories.
(2)* The separation shall have a minimum 2-hour fire resistance rating where the exit connects four or more stories, unless one of the following conditions exists:
(a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating.
(b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating.
(c) The minimum 1-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative to the requirement of 7.1.3.2.1(2).

5. The East exit enclosure had items being stored within the enclosure.
NOT MET: NFPA 101 Life Safety Code (2009 Edition)
7.1.10.1* General. 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.

6. The exterior exit doors within the LePage conference room had draperies obscuring the door.
NOT MET: NFPA 101 Life Safety Code (2009 Edition)
7.5.2.2.1 Hangings or draperies shall not be placed over exit doors or located so that they conceal or obscure any exit, unless otherwise provided in 7.5.2.2.2.

7. The west stair enclosure at the second floor has multiple penetrations through the rated enclosure.
NOT MET : NFPA 101 Life Safety Code (2009 Edition)
7.1.3.2.1 Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following:
(1)* The separation shall have a minimum 1-hour fire resistance rating where the exit connects three or fewer stories.
(2)* The separation shall have a minimum 2-hour fire resistance rating where the exit connects four or more stories, unless one of the following conditions exists:
(a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating.
(b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating.
(c) The minimum 1-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative to the requirement of 7.1.3.2.1(2).

8. Room 238 Telcom / electrical room has multiple penetrations that shall be sealed to resist the passage of smoke.
NOT MET : NFPA 101 Life Safety Code (2009 edition)
39.3.2.1* General. Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.7.

9. Within suite 301 oxygen tanks shall be stored where they are not subject to damage.
NOT MET: NFPA 99
9.7.2.3 Cylinders shall be protected from damage. Specific procedures shall include the following:
(1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device.
(2) Oxygen cylinders shall not be stored near elevators, gangways, or in locations where heavy moving objects will strike them or fall on them.
(3) Cylinders shall be protected from the tampering of unauthorized individuals.
(4) Cylinders or cylinder valves shall not be repaired, painted, or altered.
(5) Safety relief devices in valves or cylinders shall never be tampered with.
(6) Valve outlets clogged with ice shall be thawed with warm - not boiling - water.
(7) A torch flame shall never be permitted under any circumstances to come in contact with cylinder valves or safety devices.
(8) Sparks and flame shall be kept away from cylinders.
(9) Even if they are considered to be empty, cylinders shall never be used as rollers, supports, or for any purpose other than that for which the supplier intended them.
(10) Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 9.5.3.1.
(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
(12) Cylinders shall not be supported by radiators, steam pipes, or heat ducts.

10. The facility was unable to provide documentation which demonstrated the fire alarm system was being maintained in accordance with NFPA 72 National Fire Alarm Code.

77 Bates St. Lewiston: Trolley Medical Building

1. The facility was unable to provide documentation which demonstrated the fire alarm system was being maintained in accordance with NFPA 72 National Fire Alarm Code.

2. The facility was unable to provide documentation which demonstrated the sprinkler system pressure gauges had been either recalibrated or replaced within the last 5 years in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

K-135: While surveying the facility with the facility maintenance manager the inspector observed that the facility failed to maintain flammable and combustible liquid storage practices in the laboratory area accordance with NFPA 99 Health Care Facilities, section 10-7.2.2 as evidenced by the following observations:
a) In the main lab area 3.5 gallons of methanol (Class I-B flammable liquid) was observed outside of an approved flammable liquid storage cabinet.
b) In the pathology lab area 2 gallons of 2-Propanol exceeding 70% in solution (Class I-B flammable liquid) -and- 3 gallons of Ethyl alcohol between 95% and 100% purity (Class I-B flammable liquid) were observed stored or in use outside of an approved flammable liquid storage cabinet.
The maximum working supply of Class I,II, or III flammable liquids permitted in accordance with this standard is not more than one gallon.

K 143 Not Met.


While surveying the facility with the facility maintenance manager, this inspector observed liquid oxygen being stored in the clean equipment room servicing the ICU and the patient area known as C-2. This inspector after checking with staff was able to determine that transferring of oxygen from the large tanks to small portable tanks was occurring within the room which had not been setup or design for this purpose. No mechanical ventilation was noted and no signs could be found for when transferring was occurring, which could be posted to indicate when the operation was taking place.

K 147 Not Met.

1) This inspector in the presents of the plant engineer, observed in the Electrical Room on the ground floor (door marked G 037) several junction boxes which were missing their protective covers.

2) This inspector observed in the presents of the plant engineer, an electrical conduit which needed to be properly capped in the Electrical room labeled C-004A.

3) This inspector observed in the presents of the plant engineer, in the room with the door marked C-057, relocatable power taps which had been plugged one into another and were not secured to prevent physical damage. (This was not a patient care area.)

4) This inspector observed in the presents of the plant engineer, an open junction box above the drop ceiling tiles, which was missing its protective cover. (above the door marked A 237)

5) This inspector observed in the presents of the plant engineer, the use of an electrical extension cord in the room with the door marked B-105B.

6) During the walk-through inspection, this inspector observed, in the presents of the facility plant engineer an electrical conduit entering the elevator shaft, that had not been properly capped off, at the door location marked C-440.

K-11: While surveying the facility with the facility maintenance manager the inspector observed penetrations through the fire-resistive wall serving as separation from the adjacent non-conforming construction in the " Tel-Com " room off the Central Sterile space. Two conduits passing through the fire-rated wall assembly were found where the fire stopping material had fallen free of the conduits.

K-12: While surveying the facility with the facility maintenance manager the inspector observed an unprotected structural steel beam present in the electrical room on the ground floor of the building (Facility room designation G-023B). The unprotected span of the beam observed was approximately 16 feet. Adjacent columns appeared to be protected utilizing a drywall rating system. A minimum of Type II(111) construction is required pursuant to the standard.

K 17 Not Met.

While conducting the walk-through inspection, this inspector observed, in the presents of the plant engineer, that the corridor wall above the drop ceiling at the door location A 2-2, was not sealed to prevent the passage of smoke from the corridor to the use space behind the door.

K-018 Not Met.
While surveying the facility with the safety officer this inspector observed the doors located at F1-103 (ER) have a gap between the doors and are not smoke resistant as required.

K 20 Not Met.

1) During the walk-through inspection, this inspector observed in the presents of the facility maintenance officer, the linen chute in room designated C-2, failed to always close and latch completely. This allows for a unprotected vertical opening between multiple floors and fails to maintain the required one hour separation.

2) During the walk-through inspection, this inspector observed in the presents of the facility maintenance manager, holes above the drop ceiling tiles that penetrated the elevator shaft at the location marked AB-1. This allows for a unprotected vertical opening between multiple floors and fails to maintain the required one hour separation.

3) During the walk-through inspection, this inspector observed in the presents of the facility plant engineer, that the shaft across from room B 201, above the drop ceiling tiles, the duct inside the shaft had not been properly sealed to maintain the required one-hour fire separation.

4) During the walk-through inspection, this inspector observed in the presents of the facility plant engineer, that non rated "pink insulation" material had been used to seal a penetration around where a conduit passed through the wall into a elevator shaft at the door location marked C-478.

5) During the walk-through inspection, this inspector observed in the presents of the facility plant engineer, penetrations above the drop ceiling tiles entering the elevator shaft for elevator 6, 4th floor, D area.

6) During the walk-through inspection, this inspector observed in the presents of the facility maintenance manager, penetration in the Electrical closet that appeared to enter the elevator shaft in the location where the door is marked 3-C.

K-025 Not Met.
1) While surveying the facility with the safety officer this inspector observed that the fire/smoke barrier above the doors located at C1-3 has several penetrations that were not sealed as required.

2) This inspector observed in the presents of the plant engineer that holes were located above the drop ceiling tiles located above door B4-3. This wall is required to be at least one-hour fire rated and had penetrations through it which were not fully sealed.

3) This inspector observed in the presents of the plant engineer that holes were located above the drop ceiling tiles located above the door marked D3-1. This wall is required to be at least one-hour fire rated and had missing gypsum wallboard and holes that were not fully sealed.

4) This inspector observed in the presents of the plant engineer that holes were located above the drop ceiling tiles located above the double doors mark G 0-5. This wall is required to be at least one-hour fire rated.

5) This inspector observed in the presents of the plant engineer that holes were located above the drop ceiling located in room with the door marked G-027. This wall is required to be at least one-hour fire rated.

6) This inspector observed in the presents of the plant engineer holes from the Electrical room to the corridor outside. This was noted in the room with the door marked C 044. This wall is required to be at least one-hour fire rated.

7) This inspector observed in the presents of the plant engineer holes in one of the main Electrical rooms (door marked G 037) to the corridor outside. This wall is required to be at least one-hour fire rated.

8) This inspector observed in the presents of the plant engineer, penetrations above the drop ceiling, at the door location marked WSH 2-B. The penetrations appeared to have been filled with fire rated mineral wool batting but had not been sealed over with a fire rated sealant to form the required listed fire rated assembly, in order to maintain the required one-hour fire rating.

9) This inspector observed, in the presents of the plant engineer, above the drop ceiling tiles, the penetration of the sprinkler piping, had not been properly sealed to maintain the required one-hour fire rating at the cross corridor door marked D-042.

K- 27 not met.
1) This inspector observed in the presents of the plant engineer that the cross corridor doors outside the Outpatient Nurses's station did not meet the requirement of having at least a 20 minute fire protection rating. The doors had labels which specifically stated they were "unable to be labeled".

2) While surveying the facility with the safety officer this inspector observed the double doors labeled AB 3-4 have a gap between the meeting edges of the doors greater then the allowed 1/8" plus or minus a 1/16" as required by NFPA 80 Standard for Fire Doors and Other Opening Protectives.

3) While surveying the facility with the safety officer this inspector observed the double doors labeled AB 1-5 have a gap between the meeting edges of the two doors greater then the allowed 1/8" plus or minus 1/16" as required by NFPA 80 Standard for Fire Doors and Other Opening Protectives.

K-29 not met:
1) While surveying the facility with the facility maintenance manager the inspector observed that the fire rated door assembly opening from the Pathology lab into the lab corridor space had been secured in the open position utilizing a wooden wedge in violation of the standard. The wedge was removed at the time of the discovery and the maintenance manager verbally informed staff present at the time of the inspection that the practice of wedging fire doors open was prohibited.

2) While surveying the facility with the safety officer this inspector observed that the door on the soiled utility room located at F1-103 did not latch as required.

3) During the survey of the facility this inspector in the presents of the plant engineer observed a large passageway from the boiler room to the void space above the operating rooms which had not been sealed as required to maintain the required one hour fire rated separation. This passage way allowed various conduits and pipes to feed other locations of the hospital.

4) While surveying the facility, this inspector observed that the door and the door frame into the soiled laundry room (door marked A-345) did not meet the requirements listed under NFPA 80, Standard for Fire Doors and Other Opening Protectives, for a 3/4 hour fire rated door, due to unfilled holes in the doorframe and missing screws in the hinges.

K-30: While surveying the facility with the facility maintenance manager the inspector observed that the gift shop storage area lacked smoke resistive separation between the storage area and the gift shop sales area. The door opening between the gift shop storage area and the sales area must be provided with a self-closing and positively latching door assembly that is capable of resisting the passage of smoke in accordance with NFPA 101 Life Safety Code sections 19.3.2.1, 19.3.2.5, 8.3, and 8.4 (2000 edition).

K-33:
1) While surveying the facility with the facility maintenance manager the inspector observed that one of the doors opening into an egress stairwell on the ground floor failed to meet the required one-hour fire resistance rating required by the standard. (Facility door designation H0045). The 90 minute rated fire door assembly was found to have a vision panel rated to only a 45 minute fire-resistive rating according to the markings present on the door glazing at the time of the inspection.

2) While surveying the facility with the facility maintenance manager, this inspector observed holes existing above the drop ceiling tiles, which penetrated into the stair enclosure at the D3-1 FD door location.

3) While surveying the facility with the facility maintenance manager this inspector observed holes existing above the drop ceiling tiles, (which had been filed with Pink Insulation material), which penetrated into the stair enclosure at the D3-2 FD door location.

4) While surveying the facility with the facility maintenance manager this inspector observed holes existing above the drop ceiling tiles, which penetrated into the stair enclosure at the D 2-1 FD door location.

5) During the walk-through inspection, this inspector observed in the presents of the facility plant engineer, above the drop ceiling tiles, penetrations into the stair enclosure at the door location marked A237. In several of these locations it appeared Duct Tape had been used to seal the holes and where wall joints came together.

6) During the walk-through inspection, this inspector observed in the presents of the facility plant engineer, above the drop ceiling tiles (door marked WS 2-2), that the walls had not been properly sealed to the floor pan above. Fire rated mineral wool batting appears to have been installed but was not sealed over with a fire rated sealant to form the required listed fire rated assembly, in order to maintain the required one-hour fire rated enclosure.

K 38 not met.
During the walk-through inspection, this inspector observed in the presents of the plant engineer, a section of corridor (approx. 56 ft. 6 in.) in the A & B first floor level 1 wing which did not provide the proper head height as required (84"). When measured the ceiling height was between 76 1/4" and 77". Within this section of corridor, 5 doors were also observed entering into normally occupied spaces, which did not provide the proper head height as required for doors (80"). When measured these door provided 77" for a clear opening in height.

K-39: While surveying the facility with the facility maintenance manager the inspector observed that the corridor space outside the gift shop was reduced in clear width to approximately 6 feet due to the merchandising of sales items in the corridor space. The required clear width of the corridor in accordance with the standard is not less than 8 feet.

K 56 Not Met.

During the walk-through inspection of the facility, in the presents of the facility safety officer a large storage room was found which had not been protected by the installed sprinkler system as required under NFPA 13 in two locations. One location was B 200 and the other location was B 300 which sits directly above the first location cited.

K-130 offsite facility office buildings surveyed under NFPA Life Safety Code 101, 2009 Edition.


1. No records for the operation and maintenance of any of the off-site facilities emergency systems were available at the various locations for review.

2. No records demonstrating testing of the exits signs specifically could be shown by the facility for any off-site location. Currently "Emergency Lights" and "Exits Signs" are grouped under one category listed as Emergency Lighting.

100 Campus Avenue, Lewiston: Breast Health
1. Ceiling height in the Breast Health Suite was found to measure 6 feet and 6.5 inches above the finished floor level in access hallway within the suite space. In other locations the ceiling height was found to measure approximately 7 feet and 3 inches in height.
NOT MET: NFPA 101 Life Safety Code (2009 edition) Section 7.5.1: In existing buildings, the ceiling height shall be not less than 7 ft (2135 mm) from the floor, with projections from the ceiling not less than 6 ft 8 in. (2030 mm) nominal above the floor.

2. Penetrations were observed in the elevator machinery room wall located in the Breast Health suite. Damage to the rated wall assembly was observed above the door and a gap of approximately ? inch was observed around ducts penetrating the wall.
NOT MET: NFPA 101 Life Safety Code (2009 edition), Sections 39.3.2 and 8.7

3. Additional spare fire sprinkler heads must be provided. Each type of fire sprinkler present in the protected facility must have a stocked replacement heads present.
At the time of the inspection an insufficient quantities and types of spare fire sprinkler heads were present in the spare supply box for the system.
NOT MET: NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (2008 edition), Section 5.2.1.3

963 Sabattus Street, Lewiston: Sabattus Primary Care
1. Several locking or latching devices were observed on required exterior egress doors. Not more than one releasing operation is permitted to open a door in the required means of egress.
NOT MET: NFPA 101 Life Safety Code (2009 edition) Section 7.2.1.5.9.2: The releasing mechanism shall open the door leaf with not more than one releasing operation, unless otherwise specified in 7.2.1.5.9.3 and 7.2.1.5.9.4. Section 7.2.1.5.9.3 and 7.2.1.5.9.4 apply to residential locking arrangements.

3 Willow Run, Auburn: L-A Internal Medicine
1. The egress stairwell door at the basement level of the building must fully close and latch in the closed position. At the time of the inspection the door would not fully close or latch with the force applied by the self-closing device on the door.
NOT MET: NFPA 101 Life Safety Code (2009 edition) Sections 39.3.1, 8.6, and 7.1.3.2.1

2. The required means of egress discharging directly at grade from the basement level of the building is arranged so that occupants must pass through the basement storage area to access the exit. Access to a required means of egress cannot be through an area defined as a hazardous area.
NOT MET: NFPA 101 Life Safety Code (2009 edition) Section 7.5.1.6: Exit access from rooms or spaces shall be permitted to be through adjoining or intervening rooms or areas, provided that such rooms or areas are accessory to the area served. Foyers, lobbies, and reception rooms constructed as required for corridors shall not be construed as intervening rooms. Exit access shall be arranged so that it is not necessary to pass through any area identified under Protection from Hazards in Chapters 11 through 43.

3. The basement heating and storage area lacks the required one hour fire-resistive hazard area separation from the remainder of the building. The wall partitions separating the area from the remainder of the building are not continuous to the ceiling assembly above the space. The ceiling assembly also does not meet the requirement of a one hour fire-resistive assembly as it was observed at the time of the inspection to be exposed OSB/plywood. The heating and storage space contained paper file storage, air handling equipment, and a fuel fired heating device at the time of inspection.
NOT MET: NFPA 101 Life Safety Code (2009 edition) Sections 39.3.2.1 and 8.7: Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.7.

4. More than one latching/locking device was observed on some of the exterior exit doors for the practice. Panic exit hardware and turn-style deadbolt devices were in use simultaneously on exterior doors in the required means of egress. Not more than one releasing operation is permitted to open a door in the required means of egress.
NOT MET: NFPA 101 Life Safety Code (2009 edition) Section 7.2.1.5.9.2: The releasing mechanism shall open the door leaf with not more than one releasing operation, unless otherwise specified in 7.2.1.5.9.3 and 7.2.1.5.9.4. Section 7.2.1.5.9.3 and 7.2.1.5.9.4 apply to residential locking arrangements.

5. A round, graspable handrail must be provided at both sides of the exterior rear exit stair serving the exit door adjacent to the stairwell to the basement level
NOT MET: NFPA 101 Life Safety Code (2009 edition) Section 7.2.2.4.1

60 Second Street, Auburn: Second Street Family Practice
1. At the time of the inspection exit access to the exit door from the staff reception area was observed to be restricted to approximately 27 inches in clear width. Storage of a drinking water dispenser, photocopiers, and supplies obstructed the available clear exit access width.
NOT MET: NFPA 101 Life Safety Code (2009 edition) Sections 7.3.4 and 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.
7.3.4.1 The width of any means of egress, unless otherwise provided in 7.3.4.1.1 through 7.3.4.1.3, shall be as follows:
(1) Not less than that required for a given egress component in this chapter or Chapters 11 through 43
(2) Not less than 36 in. (915 mm)

2. A round, graspable handrail must be provided at both sides of the exit steps adjacent to the billing office.
NOT MET: NFPA 101 Life Safety Code (2009 edition) Section 7.2.2.4.1

3. Hazard signage in accordance with NFPA 704 Standard System for the
Identification of the Hazards of Materials for Emergency Response must be placed on the container -and- at the entrance of the room or space where the liquid nitrogen is used. At the time of the inspection one Dewar Flask of liquid nitrogen with a liquid capacity of approximately 35 liters was observed in the procedure room. While warning signage was present at the time of the inspection, no NFPA 704 compliant hazard identification system warnings were observed to be present.
NOT MET: NFPA 55 Standard for the Storage, Use, and Handling of Compressed Gases and Cryogenic Fluids in Portable and Stationary Containers, Cylinders, and Tanks (2005 edition) Section 8.4.1.3: Identification Signs. Visible hazard identification signs shall be provided in accordance with NFPA 704, Standard System for the Identification of the Hazards of Materials for Emergency Response, at entrances to buildings or areas in which cryogenic fluids are stored, handled, or used.

4. Noted on the latest sprinkler system inspection report, insufficient sprinkler system coverage was found in the computer room and needs to be corrected. (noted 1/12/12 report)

1230 Maine Street, Poland: Poland Family Practice
1. Oxygen supply room was not identified with warning signs as required ( NFPA 99).

2. The stairs to basement were not provided with approved guards.

3. The boiler room is not separated from the basement area with the required 1 hour fire
rated walls and door.

Two Great Falls Plaza, Auburn: St Mary ' s Orthopedics (2nd floor office suite)
1. The office space was not provided with approved oxygen warning signs (NFPA 99)

2. No spare sprinkler heads were noted on the latest documentation available for review of the sprinkler system inspection reports. (noted 9/21/11)

3. The facility was unable to provide documentation which demonstrated the fire alarm system was being maintained in accordance with NFPA 72 National Fire Alarm Code.

583 Lisbon Road, Lisbon Falls: Lisbon Falls Healthcare
1. Exit door eastside of building would not open without forcing the door.

2. Oxygen supply room was not provided with approved warning signs (NFPA 99)

3. Reviewing the sprinkler system inspection reports the last 2 reports noted corrosion on certain sprinkler heads, which need to be replaced. (NFPA 13 & 25)

4. Reviewing the building fire alarm system inspection reports, the last 2 reports (dated 3/2011 & 1/5/12) have noted on-going deficiencies, which have not been properly addressed or corrected. (NFPA 72)

106 Campus Ave. Lewiston: Lewiston Medical Associates
1. Emergency lights located in the hallway of the practice not working
NOT MET : NFPA 101 Life Safety Code (2009 Edition) 4.5.8 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained, unless the Code exempts such maintenance.

2. Several fire rated doors within the exit enclosure were being held open at the time of inspection
NOT MET : NFPA 101 Life Safety Code (2009 edition) 7.2.1.8.1* A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3.

3. All Exterior doors shall have a level landing on both sides of the door
NOT MET: NFPA 101 Life safety Code (2009 Edition) 7.2.1.3.1 The elevation of the floor surfaces on both sides of a door opening shall not vary by more than ? in. (13 mm), unless otherwise permitted by 7.2.1.3.5 or 7.2.1.3.6. 7.2.1.3.2 The elevation of the floor surfaces required by 7.2.1.3.1 shall be maintained on both sides of the door openings for a distance not less than the width of the widest leaf.

4. Provide an exit sign at the main entrance to the building
NOT MET : NFPA 101 Life Safety Code 101 (2009 Edition) 39.2.10 Marking of Means of Egress. Means of egress shall have signs in accordance with Section 7.10.

99 Campus Ave, Lewiston:
4 story business office occupancy

1. The emergency light within the first floor electrical room was not working at the time of inspection.
NOT MET: NFPA 101 Life Safety Code(2009 Edition)
39.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

2. Multiple penetrations within the 2 hour fire separation between the hospital occupancy and the business occupancy were observed above the ceiling tile .
NOT MET: NFPA 101 Life Safety Code (2009 Edition)
19.1.1.4.1 Additions. Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition.

3. Exit sign on the exterior door within the connector was not illuminated at the time of the inspection.
NOT MET: NFPA 101 Life Safety Code (2009 Edition)
39.2.10 Marking of Means of Egress. Means of egress shall have signs in accordance with Section 7.10.

4. The west stair enclosure at the first floor has multiple penetrations through the rated enclosure.
NOT MET : NFPA 101 Life Safety Code (2009 Edition)
7.1.3.2.1 Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following:
(1)* The separation shall have a minimum 1-hour fire resistance rating where the exit connects three or fewer stories.
(2)* The separation shall have a minimum 2-hour fire resistance rating where the exit connects four or more stories, unless one of the following conditions exists:
(a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating.
(b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating.
(c) The minimum 1-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative to the requirement of 7.1.3.2.1(2).

5. The East exit enclosure had items being stored within the enclosure.
NOT MET: NFPA 101 Life Safety Code (2009 Edition)
7.1.10.1* General. 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.

6. The exterior exit doors within the LePage conference room had draperies obscuring the door.
NOT MET: NFPA 101 Life Safety Code (2009 Edition)
7.5.2.2.1 Hangings or draperies shall not be placed over exit doors or located so that they conceal or obscure any exit, unless otherwise provided in 7.5.2.2.2.

7. The west stair enclosure at the second floor has multiple penetrations through the rated enclosure.
NOT MET : NFPA 101 Life Safety Code (2009 Edition)
7.1.3.2.1 Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following:
(1)* The separation shall have a minimum 1-hour fire resistance rating where the exit connects three or fewer stories.
(2)* The separation shall have a minimum 2-hour fire resistance rating where the exit connects four or more stories, unless one of the following conditions exists:
(a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating.
(b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating.
(c) The minimum 1-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative to the requirement of 7.1.3.2.1(2).

8. Room 238 Telcom / electrical room has multiple penetrations that shall be sealed to resist the passage of smoke.
NOT MET : NFPA 101 Life Safety Code (2009 edition)
39.3.2.1* General. Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.7.

9. Within suite 301 oxygen tanks shall be stored where they are not subject to damage.
NOT MET: NFPA 99
9.7.2.3 Cylinders shall be protected from damage. Specific procedures shall include the following:
(1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device.
(2) Oxygen cylinders shall not be stored near elevators, gangways, or in locations where heavy moving objects will strike them or fall on them.
(3) Cylinders shall be protected from the tampering of unauthorized individuals.
(4) Cylinders or cylinder valves shall not be repaired, painted, or altered.
(5) Safety relief devices in valves or cylinders shall never be tampered with.
(6) Valve outlets clogged with ice shall be thawed with warm - not boiling - water.
(7) A torch flame shall never be permitted under any circumstances to come in contact with cylinder valves or safety devices.
(8) Sparks and flame shall be kept away from cylinders.
(9) Even if they are considered to be empty, cylinders shall never be used as rollers, supports, or for any purpose other than that for which the supplier intended them.
(10) Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 9.5.3.1.
(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
(12) Cylinders shall not be supported by radiators, steam pipes, or heat ducts.

10. The facility was unable to provide documentation which demonstrated the fire alarm system was being maintained in accordance with NFPA 72 National Fire Alarm Code.

77 Bates St. Lewiston: Trolley Medical Building

1. The facility was unable to provide documentation which demonstrated the fire alarm system was being maintained in accordance with NFPA 72 National Fire Alarm Code.

2. The facility was unable to provide documentation which demonstrated the sprinkler system pressure gauges had been either recalibrated or replaced within the last 5 years in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

K-135: While surveying the facility with the facility maintenance manager the inspector observed that the facility failed to maintain flammable and combustible liquid storage practices in the laboratory area accordance with NFPA 99 Health Care Facilities, section 10-7.2.2 as evidenced by the following observations:
a) In the main lab area 3.5 gallons of methanol (Class I-B flammable liquid) was observed outside of an approved flammable liquid storage cabinet.
b) In the pathology lab area 2 gallons of 2-Propanol exceeding 70% in solution (Class I-B flammable liquid) -and- 3 gallons of Ethyl alcohol between 95% and 100% purity (Class I-B flammable liquid) were observed stored or in use outside of an approved flammable liquid storage cabinet.
The maximum working supply of Class I,II, or III flammable liquids permitted in accordance with this standard is not more than one gallon.

K 143 Not Met.


While surveying the facility with the facility maintenance manager, this inspector observed liquid oxygen being stored in the clean equipment room servicing the ICU and the patient area known as C-2. This inspector after checking with staff was able to determine that transferring of oxygen from the large tanks to small portable tanks was occurring within the room which had not been setup or design for this purpose. No mechanical ventilation was noted and no signs could be found for when transferring was occurring, which could be posted to indicate when the operation was taking place.

K 147 Not Met.

1) This inspector in the presents of the plant engineer, observed in the Electrical Room on the ground floor (door marked G 037) several junction boxes which were missing their protective covers.

2) This inspector observed in the presents of the plant engineer, an electrical conduit which needed to be properly capped in the Electrical room labeled C-004A.

3) This inspector observed in the presents of the plant engineer, in the room with the door marked C-057, relocatable power taps which had been plugged one into another and were not secured to prevent physical damage. (This was not a patient care area.)

4) This inspector observed in the presents of the plant engineer, an open junction box above the drop ceiling tiles, which was missing its protective cover. (above the door marked A 237)

5) This inspector observed in the presents of the plant engineer, the use of an electrical extension cord in the room with the door marked B-105B.

6) During the walk-through inspection, this inspector observed, in the presents of the facility plant engineer an electrical conduit entering the elevator shaft, that had not been properly capped off, at the door location marked C-440.