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Based on observation and staff interview, the facility failed to assure that corridor doors close tightly to prevent gaps, allowing the spread of smoke and fire. This affects 1 of 3 smoke zones. The facility has a capacity of 25 with a census of 13.

Findings include:

During the tour on 4/6/11 between 1:30 PM and 4:30 PM it is observed there is a cardboard wedge obstructing the latching hardware from latching the door to the door frame to Staff Lounge 728.

Staff A, Staff B, Fire Chief and Contractors were present and aware of the finding. Staff B stated the entrance into the lounge is by way of staff ID cards. The cards received by the hospital were the incorrect cards to enter the staff lounge and that is why the cardboard was obstructing the latching hardware.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and staff interview the facility is not assuring that one of four smoke barriers is free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects 3 of 3 smoke zones. This facility has a capacity of 25 and a census of 13.

Findings include:

During the tour on 4/6/11 between 1:30 PM and 4:30 PM the following is observed:

--1) There is a hole in the 2 hour wall by 221.
--2) There is a gap around a water pipe, hole in the wall by the damper and a penetration around a Unistrute green pipe in the 1 hour wall by 728 Staff Lounge.
--3) There is sheet rock missing around a bar joist and an open wire chase in the 1 hour wall by 717.
--4) There is sheet rock missing beside an electrical box on the west side of the wall on the 2 hour wall by Surgery.
--5) There is a gap around a green conduit where caulking has come loose on the 2 hour wall by 762.

Staff A, Staff B, Fire Chief and Contractors were present and aware of the findings. Contractors made notes of the findings.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting 1 of 3 smoke zones. This facility has a capacity of 25 and a census of 13.

Findings include:

During the tour on 4/6/11 between 1:30 PM and 4:30 PM the following is observed:

--1) There are gaps around metal rafters on the west wall of the Emergency Power room.
--2) There is a hole in the upper wall where blue computer wires are ran through the east wall of the Emergency Power room.
--3) There is an open electrical conduit above the door of the SE wall of the Mechanical room.
--4) There are gaps between multiple metal rafters on the east wall of the Emergency Power room.
--5) There are gaps around three medical air lines on the north wall of the Emergency Power room.
--6) There is a wooden wedge blocking open the self closing door to Housekeeping 920.

Staff A, Staff B, Fire Chief and Contractors were present and confirmed the finding. Staff B removed the wedge from the housekeeping door.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation and staff interview, this facility is not providing an all-weather surface from each exit to a public way (an area of safety). This deficiency fails to ensure that all exits are accessible, affecting 2 of 3 smoke zones. This facility has a capacity of 25 with a census of 13.

Findings include:

During the tour on 4/6/11 between 1:30 PM and 4:30 PM the following is observed:
--1) There is no sidewalk to a public way out of the NW exit.
--2) There is no sidewalk to a public way out of the S exit.
Staff A, Staff B, Fire Chief and Contractors were present and confirmed the findings. Staff B stated the sidewalks will be completed by June 2011.
NFPA Standard: 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. 2000 NFPA 101, 7.1.10.1

Based on observation and staff interview, the facility failed to provide emergency lighting of at least 1?-hour duration at a delayed egress exit doors, as required by NFPA 99. The deficient practice could leave the area in darkness in the event of a power failure, causing a delay in exiting. This deficiency affects 1 of 3 smoke zones. The facility has a capacity of 25 with a census of 13.

Findings include:

During the tour on 4/6/11 between 1:30 PM and 4:30 PM it is observed the overhead light at the 30 second delay door can be turned off with a manual switch in the Mother/Baby ward.

Staff A, Staff B Fire Chief and Contractors were present and confirmed the finding. Staff B was not aware of the deficiency.

NFPA Standard: Emergency lighting for means of egress shall be provided in accordance with Section 7.9 for the following: buildings or structures where required by the occupancy chapters, underground and windowless structures as required by Section 11.7, high-rise buildings as required by other sections of this Code, doors equipped with delayed egress locks, and stair shaft and vestibules of smoke proof enclosures. For the purposes of this requirement, exit access shall include designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit and exit discharge shall include designated stairs, ramps, aisles, walkways, and escalators leading to a public way. 2000 NFPA 101, 7.9.1.1

Based on observation and staff interview the facility failed to ensure that portable fire extinguishers are properly mounted. This deficient practice may prevent the portable fire extinguisher from being readily accessible due to difficulty in retrieving it from the mounting bracket, affecting 1 of 3 smoke zones. The facility has a capacity of 25 and a census of 13.

Findings include:
During the tour on 4/6/11 between 1:30 PM and 4:30 PM the following is observed:
--1) The fire extinguisher is obstructed by two large barrels and a cart in Laundry.
--2) The K-type fire extinguisher is sitting on the floor in the Kitchen.

Staff A, Staff B, Fire Chief and Contractors were present and confirmed the finding. Staff B stated the K-type will be mounted on the wall in the kitchen.

NFPA Standard: Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas. 1998 NFPA 10, 1-6.3

Based on observation and staff interview the facility failed to ensure that the means of egress are continuously maintained free of all obstructions or impediments, which would prevent full instant use of the means of egress in the case of a fire or other emergency. This deficiency affects 1 of 3 smoke zones. This facility has a capacity of 25 with a census of 13.

Findings include:

During the tour on 4/6/11 between 1:30 PM and 4:30 PM the following is observed:

--1) There are two housekeeping carts stored in the exit corridor in the West hall.
--2) There is a large metal rack and boxes stored in the Service hall exit corridor.
--3) There is a portable cart containing 10 full oxygen tanks that is stored in the Service Hall exit corridor.

Staff A, Staff B, Fire Chief and Contractors were present and confirmed the finding. Staff C stated one of the housekeeping carts would be left in the exit corridor for at least 1 hour while the staff member that uses this cart is picking up trash. Surveyor requested the mobile oxygen cart with full O2 tanks be removed out of the exit corridor.

NFPA standards: No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1

Based on observation and staff interview the facility failed to ensure that empty and full oxygen cylinders were not stored in separate racks. This deficient practice could cause an empty cylinder to be retrieved in an emergency situation, affecting 1 of 3 smoke zones. The facility has a capacity 25 and a census of 13.

Findings include:

During the tour on 4/6/11 between 1:30 PM and 4:30 PM it is observed there are two empty oxygen tanks stored in the full mobile rack in the Cardio Pulmonary Lab 505.

Staff A, Staff B Fire Chief and Contractors were present and confirmed the finding. Staff N stated they thought there was an exception with mobile oxygen racks with 12 or less tanks.

NFPA Standard: Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. 1999 NFPA 99, 4.3.1.1.2

Based on observation and staff interview, the facility failed to assure that corridor doors close tightly to prevent gaps, allowing the spread of smoke and fire. This affects 1 of 3 smoke zones. The facility has a capacity of 25 with a census of 13.

Findings include:

During the tour on 4/6/11 between 1:30 PM and 4:30 PM it is observed there is a cardboard wedge obstructing the latching hardware from latching the door to the door frame to Staff Lounge 728.

Staff A, Staff B, Fire Chief and Contractors were present and aware of the finding. Staff B stated the entrance into the lounge is by way of staff ID cards. The cards received by the hospital were the incorrect cards to enter the staff lounge and that is why the cardboard was obstructing the latching hardware.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and staff interview the facility is not assuring that one of four smoke barriers is free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects 3 of 3 smoke zones. This facility has a capacity of 25 and a census of 13.

Findings include:

During the tour on 4/6/11 between 1:30 PM and 4:30 PM the following is observed:

--1) There is a hole in the 2 hour wall by 221.
--2) There is a gap around a water pipe, hole in the wall by the damper and a penetration around a Unistrute green pipe in the 1 hour wall by 728 Staff Lounge.
--3) There is sheet rock missing around a bar joist and an open wire chase in the 1 hour wall by 717.
--4) There is sheet rock missing beside an electrical box on the west side of the wall on the 2 hour wall by Surgery.
--5) There is a gap around a green conduit where caulking has come loose on the 2 hour wall by 762.

Staff A, Staff B, Fire Chief and Contractors were present and aware of the findings. Contractors made notes of the findings.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting 1 of 3 smoke zones. This facility has a capacity of 25 and a census of 13.

Findings include:

During the tour on 4/6/11 between 1:30 PM and 4:30 PM the following is observed:

--1) There are gaps around metal rafters on the west wall of the Emergency Power room.
--2) There is a hole in the upper wall where blue computer wires are ran through the east wall of the Emergency Power room.
--3) There is an open electrical conduit above the door of the SE wall of the Mechanical room.
--4) There are gaps between multiple metal rafters on the east wall of the Emergency Power room.
--5) There are gaps around three medical air lines on the north wall of the Emergency Power room.
--6) There is a wooden wedge blocking open the self closing door to Housekeeping 920.

Staff A, Staff B, Fire Chief and Contractors were present and confirmed the finding. Staff B removed the wedge from the housekeeping door.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation and staff interview, this facility is not providing an all-weather surface from each exit to a public way (an area of safety). This deficiency fails to ensure that all exits are accessible, affecting 2 of 3 smoke zones. This facility has a capacity of 25 with a census of 13.

Findings include:

During the tour on 4/6/11 between 1:30 PM and 4:30 PM the following is observed:
--1) There is no sidewalk to a public way out of the NW exit.
--2) There is no sidewalk to a public way out of the S exit.
Staff A, Staff B, Fire Chief and Contractors were present and confirmed the findings. Staff B stated the sidewalks will be completed by June 2011.
NFPA Standard: 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. 2000 NFPA 101, 7.1.10.1

Based on observation and staff interview, the facility failed to provide emergency lighting of at least 1?-hour duration at a delayed egress exit doors, as required by NFPA 99. The deficient practice could leave the area in darkness in the event of a power failure, causing a delay in exiting. This deficiency affects 1 of 3 smoke zones. The facility has a capacity of 25 with a census of 13.

Findings include:

During the tour on 4/6/11 between 1:30 PM and 4:30 PM it is observed the overhead light at the 30 second delay door can be turned off with a manual switch in the Mother/Baby ward.

Staff A, Staff B Fire Chief and Contractors were present and confirmed the finding. Staff B was not aware of the deficiency.

NFPA Standard: Emergency lighting for means of egress shall be provided in accordance with Section 7.9 for the following: buildings or structures where required by the occupancy chapters, underground and windowless structures as required by Section 11.7, high-rise buildings as required by other sections of this Code, doors equipped with delayed egress locks, and stair shaft and vestibules of smoke proof enclosures. For the purposes of this requirement, exit access shall include designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit and exit discharge shall include designated stairs, ramps, aisles, walkways, and escalators leading to a public way. 2000 NFPA 101, 7.9.1.1

Based on observation and staff interview the facility failed to ensure that portable fire extinguishers are properly mounted. This deficient practice may prevent the portable fire extinguisher from being readily accessible due to difficulty in retrieving it from the mounting bracket, affecting 1 of 3 smoke zones. The facility has a capacity of 25 and a census of 13.

Findings include:
During the tour on 4/6/11 between 1:30 PM and 4:30 PM the following is observed:
--1) The fire extinguisher is obstructed by two large barrels and a cart in Laundry.
--2) The K-type fire extinguisher is sitting on the floor in the Kitchen.

Staff A, Staff B, Fire Chief and Contractors were present and confirmed the finding. Staff B stated the K-type will be mounted on the wall in the kitchen.

NFPA Standard: Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas. 1998 NFPA 10, 1-6.3

Based on observation and staff interview the facility failed to ensure that the means of egress are continuously maintained free of all obstructions or impediments, which would prevent full instant use of the means of egress in the case of a fire or other emergency. This deficiency affects 1 of 3 smoke zones. This facility has a capacity of 25 with a census of 13.

Findings include:

During the tour on 4/6/11 between 1:30 PM and 4:30 PM the following is observed:

--1) There are two housekeeping carts stored in the exit corridor in the West hall.
--2) There is a large metal rack and boxes stored in the Service hall exit corridor.
--3) There is a portable cart containing 10 full oxygen tanks that is stored in the Service Hall exit corridor.

Staff A, Staff B, Fire Chief and Contractors were present and confirmed the finding. Staff C stated one of the housekeeping carts would be left in the exit corridor for at least 1 hour while the staff member that uses this cart is picking up trash. Surveyor requested the mobile oxygen cart with full O2 tanks be removed out of the exit corridor.

NFPA standards: No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1

Based on observation and staff interview the facility failed to ensure that empty and full oxygen cylinders were not stored in separate racks. This deficient practice could cause an empty cylinder to be retrieved in an emergency situation, affecting 1 of 3 smoke zones. The facility has a capacity 25 and a census of 13.

Findings include:

During the tour on 4/6/11 between 1:30 PM and 4:30 PM it is observed there are two empty oxygen tanks stored in the full mobile rack in the Cardio Pulmonary Lab 505.

Staff A, Staff B Fire Chief and Contractors were present and confirmed the finding. Staff N stated they thought there was an exception with mobile oxygen racks with 12 or less tanks.

NFPA Standard: Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. 1999 NFPA 99, 4.3.1.1.2