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Based on observation and staff interview, the facility failed to ensure that they maintained their doors protecting corridor openings per the requirements of:

NFPA 101 Life Safety Code (LSC) 2000 edition, 19.3.6.3

This deficiency has the potential to affect all residents, staff and visitors located throughout the facility.


Findings include:

Observation during facility tour on 03/14/2016 through 03/17/2016 at approximately 0900 hrs to 1500 hrs revealed two (2) corridor doors (located on 2nd floor of main building and within cancer center) would not self close (resist the passage of smoke). *(cited corridor doors were recorded by the Compliance Manager and myself throughout tour).*

Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Doors shall be provided with a means suitable for keeping the door closed.

The Compliance Manager was present when the deficiency was identified (during walk-through 03/14/2016 through 03/17/2016). Exit interview with the Facilities Director and staff on 03/17/2016 at approximately 1345 hrs verified knowledge of two (2) corridor doors (located on 2nd floor of main building and within cancer center) not self closing (resist the passage of smoke).

The facility does have a written policy/procedure for maintaining their corridor doors, which was observed during record review (if any corridor door is observed failing during a fire drill a work order is submitted to correct the problem). The Facilities Director and staff were not aware that two (2) corridor doors (located on 2nd floor of main building and within cancer center) would not self close (resist the passage of smoke).

Based on observation and staff interview, the facility failed to ensure that they maintained their fire barrier doors per the requirements of:

NFPA 101 Life Safety Code (LSC) 2000 edition, 19.2.2.2.6, 7.2.1.8.1, 7.2.1.8.2
NFPA 72 National Fire Alarm Code 1999 edition

This deficiency has the potential to affect all residents, staff and visitors located throughout the facility.


Findings include:

Observation during facility tour on 03/14/2016 through 03/17/2016 at approximately 0900 hrs to 1500 hrs revealed numerous fire barrier doors throughout facility would not self close/latch (resist the passage of fire/smoke). *Most fire barrier doors were fixed before end of survey (doors had labeling system, due to amount, and cited doors were recorded by the Compliance Manager and myself throughout tour).*

In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be
automatic-closing, provided that the following criteria are met:

(1) Upon release of the hold-open mechanism, the door
becomes self-closing.
(2) The release device is designed so that the door instantly
releases manually and upon release becomes self-closing,
or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated
by the operation of approved smoke detectors
installed in accordance with the requirements for smoke
detectors for door release service in NFPA 72, National
Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold-open
mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in
a stair enclosure results in closing all doors serving that
stair.

The Compliance Manager was present when the deficiency was identified (during walk-through 03/14/2016 through 03/17/2016). Exit interview with the Facilities Director and staff on 03/17/2016 at approximately 1345 hrs verified knowledge of numerous fire barrier doors throughout facility that would not self close/latch (resist the passage of fire/smoke).

The facility does have a written policy/procedure for maintaining their fire barrier doors, which was observed during record review (if any fire barrier door is observed failing during a fire drill a work order is submitted to correct the problem). The Facilities Director and staff were not aware that numerous fire barrier doors throughout facility would not self close/latch (resist the passage of fire/smoke).

Based on observation and staff interview, the facility failed to ensure that they maintained their fire alarm systems per the requirements of:

NFPA 101 Life Safety Code (LSC) 2000 edition, 9.6.1.4, 9.6.1.7
NFPA 70 National Electrical Code 1999 edition
NFPA 72 National Fire Alarm Code 1999 edition 2-8.2.1

This deficiency has the potential to affect all residents, staff and visitors located throughout the facility.


Findings include:

Observation during facility tour on 03/16/2016 through 03/17/2016 at approximately 0900 hrs to 1500 hrs revealed Tower Cafe had a cart piled 5 feet high with racks of bread blocking a fire alarm pull station and hood suppression activation.

Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

The Compliance Manager was present when the deficiency was identified (during walk-through 03/16/2016 through 03/17/2016). Exit interview with the Facilities Director and staff on 03/17/2016 at approximately 1345 hrs verified knowledge of Tower Cafe having a cart piled 5 feet high with racks of bread blocking a fire alarm pull station and hood suppression activation.

The facility does have a written policy/procedure for keeping all fire alarm pull stations, fire extinguishers and any other fire alarm initiating device free and clear of obstructions. The Facilities Director and staff were not aware that the Tower Cafe had a cart piled 5 feet high with racks of bread blocking a fire alarm pull station and hood suppression activation, and as a result they will reiterate the policy/procedure for keeping all fire alarm pull stations, fire extinguishers and any other fire alarm initiating device free and clear of obstructions.

Based on observation and staff interview, the facility failed to ensure that they maintained their electrical wiring and equipment per the requirements of:

NFPA 101 Life Safety Code (LSC) 2000 edition, 9.1.2
NFPA 70 National Electrical Code 1999 edition
NFPA 99 Standard for Health Care Facilities 1999 edition

This deficiency has the potential to affect all residents, staff and visitors located throughout the facility.


Findings include:

Observation during facility tour on 03/14/2016 through 03/17/2016 at approximately 0900 hrs to 1500 hrs revealed numerous private offices throughout facility were powering appliances (refrigerators) via a power strip. *(cited offices were recorded by the Compliance Manager and myself throughout tour).*


Power strips are designed to be used with several low-amperage loads, such as desktop computers and peripherals. Power strips must not be connected to high-amperage loads, such as refrigerators, space heaters, microwave ovens or air conditioners that are likely to overload the strip.

The Compliance Manager was present when the deficiency was identified (during walk-through 03/14/2016 through 03/17/2016). Exit interview with the Facilities Director and staff on 03/17/2016 at approximately 1345 hrs verified knowledge of numerous private offices throughout facility tour (03/14/2016 through 03/17/2016) were powering appliances (refrigerators) via a power strip.

The facility does have a written policy/procedure for authorized appliances as well as approved uses for power strips. The Facilities Director and staff were not aware that numerous private offices throughout facility tour (03/14/2016 through 03/17/2016) were powering appliances (refrigerators) via a power strip, and as a result they will reiterate the policy/procedure of power strip uses to all the facilities staff.

Based on observation and staff interview, the facility failed to ensure that they maintained their doors protecting corridor openings per the requirements of:

NFPA 101 Life Safety Code (LSC) 2000 edition, 19.3.6.3

This deficiency has the potential to affect all residents, staff and visitors located throughout the facility.


Findings include:

Observation during facility tour on 03/14/2016 through 03/17/2016 at approximately 0900 hrs to 1500 hrs revealed two (2) corridor doors (located on 2nd floor of main building and within cancer center) would not self close (resist the passage of smoke). *(cited corridor doors were recorded by the Compliance Manager and myself throughout tour).*

Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Doors shall be provided with a means suitable for keeping the door closed.

The Compliance Manager was present when the deficiency was identified (during walk-through 03/14/2016 through 03/17/2016). Exit interview with the Facilities Director and staff on 03/17/2016 at approximately 1345 hrs verified knowledge of two (2) corridor doors (located on 2nd floor of main building and within cancer center) not self closing (resist the passage of smoke).

The facility does have a written policy/procedure for maintaining their corridor doors, which was observed during record review (if any corridor door is observed failing during a fire drill a work order is submitted to correct the problem). The Facilities Director and staff were not aware that two (2) corridor doors (located on 2nd floor of main building and within cancer center) would not self close (resist the passage of smoke).

Based on observation and staff interview, the facility failed to ensure that they maintained their fire barrier doors per the requirements of:

NFPA 101 Life Safety Code (LSC) 2000 edition, 19.2.2.2.6, 7.2.1.8.1, 7.2.1.8.2
NFPA 72 National Fire Alarm Code 1999 edition

This deficiency has the potential to affect all residents, staff and visitors located throughout the facility.


Findings include:

Observation during facility tour on 03/14/2016 through 03/17/2016 at approximately 0900 hrs to 1500 hrs revealed numerous fire barrier doors throughout facility would not self close/latch (resist the passage of fire/smoke). *Most fire barrier doors were fixed before end of survey (doors had labeling system, due to amount, and cited doors were recorded by the Compliance Manager and myself throughout tour).*

In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be
automatic-closing, provided that the following criteria are met:

(1) Upon release of the hold-open mechanism, the door
becomes self-closing.
(2) The release device is designed so that the door instantly
releases manually and upon release becomes self-closing,
or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated
by the operation of approved smoke detectors
installed in accordance with the requirements for smoke
detectors for door release service in NFPA 72, National
Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold-open
mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in
a stair enclosure results in closing all doors serving that
stair.

The Compliance Manager was present when the deficiency was identified (during walk-through 03/14/2016 through 03/17/2016). Exit interview with the Facilities Director and staff on 03/17/2016 at approximately 1345 hrs verified knowledge of numerous fire barrier doors throughout facility that would not self close/latch (resist the passage of fire/smoke).

The facility does have a written policy/procedure for maintaining their fire barrier doors, which was observed during record review (if any fire barrier door is observed failing during a fire drill a work order is submitted to correct the problem). The Facilities Director and staff were not aware that numerous fire barrier doors throughout facility would not self close/latch (resist the passage of fire/smoke).

Based on observation and staff interview, the facility failed to ensure that they maintained their fire alarm systems per the requirements of:

NFPA 101 Life Safety Code (LSC) 2000 edition, 9.6.1.4, 9.6.1.7
NFPA 70 National Electrical Code 1999 edition
NFPA 72 National Fire Alarm Code 1999 edition 2-8.2.1

This deficiency has the potential to affect all residents, staff and visitors located throughout the facility.


Findings include:

Observation during facility tour on 03/16/2016 through 03/17/2016 at approximately 0900 hrs to 1500 hrs revealed Tower Cafe had a cart piled 5 feet high with racks of bread blocking a fire alarm pull station and hood suppression activation.

Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

The Compliance Manager was present when the deficiency was identified (during walk-through 03/16/2016 through 03/17/2016). Exit interview with the Facilities Director and staff on 03/17/2016 at approximately 1345 hrs verified knowledge of Tower Cafe having a cart piled 5 feet high with racks of bread blocking a fire alarm pull station and hood suppression activation.

The facility does have a written policy/procedure for keeping all fire alarm pull stations, fire extinguishers and any other fire alarm initiating device free and clear of obstructions. The Facilities Director and staff were not aware that the Tower Cafe had a cart piled 5 feet high with racks of bread blocking a fire alarm pull station and hood suppression activation, and as a result they will reiterate the policy/procedure for keeping all fire alarm pull stations, fire extinguishers and any other fire alarm initiating device free and clear of obstructions.

Based on observation and staff interview, the facility failed to ensure that they maintained their electrical wiring and equipment per the requirements of:

NFPA 101 Life Safety Code (LSC) 2000 edition, 9.1.2
NFPA 70 National Electrical Code 1999 edition
NFPA 99 Standard for Health Care Facilities 1999 edition

This deficiency has the potential to affect all residents, staff and visitors located throughout the facility.


Findings include:

Observation during facility tour on 03/14/2016 through 03/17/2016 at approximately 0900 hrs to 1500 hrs revealed numerous private offices throughout facility were powering appliances (refrigerators) via a power strip. *(cited offices were recorded by the Compliance Manager and myself throughout tour).*


Power strips are designed to be used with several low-amperage loads, such as desktop computers and peripherals. Power strips must not be connected to high-amperage loads, such as refrigerators, space heaters, microwave ovens or air conditioners that are likely to overload the strip.

The Compliance Manager was present when the deficiency was identified (during walk-through 03/14/2016 through 03/17/2016). Exit interview with the Facilities Director and staff on 03/17/2016 at approximately 1345 hrs verified knowledge of numerous private offices throughout facility tour (03/14/2016 through 03/17/2016) were powering appliances (refrigerators) via a power strip.

The facility does have a written policy/procedure for authorized appliances as well as approved uses for power strips. The Facilities Director and staff were not aware that numerous private offices throughout facility tour (03/14/2016 through 03/17/2016) were powering appliances (refrigerators) via a power strip, and as a result they will reiterate the policy/procedure of power strip uses to all the facilities staff.