HospitalInspections.org

Based on observation and staff interviews, the facility failed to assure that the 2 hour wall is sealed, failing to provide the proper fire resistance rating. This affects 4 of the 6 smoke zones. The facility has a capacity of 25 with a census of 21.

Findings Include:

During the tour on 7/12/12 and 7/16/12 between 10:30 am and 6:00 pm the following is observed:

--1) There is a gap around a conduit in the 2 hour wall between the LTCU and hospital - hospital side of wall.
--2) There are gaps around conduits, three (3) open wire chase X 2 sides, and a white foam type product filling in a penetration at the top of the 2 hour wall of the New Patient wing at the SE smoke wall.
--3) There is an open wire chase with gaps around this wire chase in the 2 hour wall on new Patient wing by room 123.
--4) The fire barrier doors are not latching with the provided latching hardware in the 2 hour wall by room 123.

Maintenance Staff A was present and acknowledged the finding. Maintenance Staff A stated there is no documentation for the white foam type product.

NFPA Standard: 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. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2

Based on observation and staff interview, the facility is not providing appropriate construction standards as required by the life safety code and a rated ceiling assembly is not provided as required by the building's construction type, which would prevent containment of smoke and/or fire, affecting 2 of 6 smoke zones. The facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) There are gaps around metal framing on the North wall of the Front Lobby Mechanical room.
--2) There are ceiling tiles out in the Front Lobby Mechanical room.
--3) There are ceiling tiles out in the Pink Ladies storage closet.
--3) There is expansion foam used to seal gaps on the upper wall of the IT Education room.

Staff A was present and acknowledged the findings.

NFPA Standard: Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2 per NFPA 101, 8.2.3.1.1. Space between wires and similar building service equipment that pass through fire barriers shall be protected by filling the space with a material that is capable of maintaining the fire resistance of the fire barrier or shall be protected by an approved device that is designed for the specific purpose 2000 NFPA 101, 8.2.3.2.4.2

Based on observation, the facility failed to maintain corridor walls with a fire resistance rating of not less than 1/2 hour and that were smoke resistive. The deficient practice affected 1 of 6 smoke zones. The facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/17 between 10:30 AM and 6:00 PM it is observed there is expansion foam filling penetrations in the non-sprinkled 400 hall exit corridor on both sides of the hall above the ceiling tiles. This deficiency was also cited during the 2008 survey.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, and shall have a fire resistance rating of not less than 1/2 hour. Exception: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system, a corridor shall be permitted to be separated from all other areas by non-rated partitions and terminate at the ceiling if the ceiling is constructed to limit the transfer of smoke. Exception: Existing corridor partitions shall be permitted to terminate at ceilings that are not an integral part of a floor construction if 5 ft or more of space exists between the top of the ceiling subsystem and the bottom of the floor or roof above, provided that the ceiling is a fire-rated assembly tested to have a fire resistance rating of not less than 1 hour in compliance with the provisions of 8.2.3.1. 2000 NFPA 101, 19.3.6.2

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 3 of 6 smoke zones. The facility has a capacity of 25 with a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) The self closing door is blocked open with a wooden wedge to Basement Housekeeping. This was corrected at time of survey.
--2) The self closing device is not latching the door to the door frame to Surgery Staff Lounge.
--3) The self closer is not latching the door to the door frame to X-Ray B.
--4) There is no latching hardware on the corridor door to IT Education room. The door does have a push button type lock on the door.
--5) The self closing door is not latching to the door frame to the exit stairwell in the Basement that leads to ER.

Maintenance Staff A was present and acknowledged the finding.

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 smoke barriers are 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 6 smoke zones. This facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) There are gaps around wires in the ER smoke wall, East side of wall by the North double doors.
--2) There are gaps around a pipe, conduits and wires on both sides of the ER smoke wall by the Boiler room.

Maintenance Staff A was present and acknowledged the finding.

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 2 of 6 smoke zones. This facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) The self closer is not latching to the basement Air Filter storage room.
--2) The self closer is not latching to the Surgery Storage room by OR 3.
--3) There is ceiling tiles out of place in the Sterilizer Boiler room.

Maintenance Staff A was present and acknowledged the finding.

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, the facility failed to provide means of egress that are maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. The deficient practice prevents exits from being arranged so that they are readily available and accessible, affecting 2 of 6 smoke zones. This facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) The emergency exit placard is showing a stairwell as an exit stairwell, which is not an exit in the South basement.
--2) There is old hospital furniture obstructing the exit access in the Old 400 Basement, exit leads into the enclosed courtyard.

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 fails to assure there is normal illumination in all exit corridors, failing to ensure that all areas of egress will not be left in total darkness. This deficient practice affects 5 of 6 smoke zones. The facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) There is no two bulb light fixture out of the Doctors North exit.
--2) The overhead lights can be turned off with a manual switch in the Surgery West exit stairwell.
--3) There is one light fixture connected to the generator in the Library exit corridor, all other lights can be turned off with a manual switch.
--4) The overhead lights can be turned off with a manual switch in the Time Clock exit corridor.
--5) The overhead lights in the nurse work station can be turned off with a manual switch in Surgery.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4

Based on observation and staff interview the facility fails to assure directional and exit signs are properly displayed. This deficient practice fails to direct occupants to a safe path of egress in case of an emergency, affecting 1 of 6 smoke zones. The facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM it is observed there is an exit sign that directs exiting from the Old 400 Basement Storage room into the 2002 Basement Storage room.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent. 2000 NFPA 101, 7.10.2

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency affecting 6 of 6 smoke zones. The facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM it is observed the fire drill scenarios are incomplete records. The scenarios do not reflect a possible "fire scenario", rather how many staff brought fire extinguishers to the fire zone.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based on record review and staff interview, the facility failed to assure that the fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. This deficiency fails to ensure that the fire alarm system control functions are working properly jeopardizing the safety of all building occupants. This deficiency would affect 6 of 6 smoke zones. This facility has a capacity 25 with a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) The last annual fire alarm inspection report available to surveyors is dated Feb 2011. The facility is five (5) months past due for the annual inspection.
--2) There is a smoke detector hanging by it's wires from the ceiling in the Front Lobby Air Handling Mechanical room.
--3) The fire alarm panel (FAP) is obstructed for immediate use with blue computer wires hanging in front of the panel. The fire alarm panel door cannot close due to the wires obstructing the panel door.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2. 1999 NFPA 72, 7-2.2

NFPA Standard: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of the code, such device, equipment, system, condition, arrangement, level of protection, or any other feature shall thereafter be maintained unless the Code exempts such maintenance. 2000 NFPA 101, 4.5.7

Based on record review and staff interview, the facility failed to maintain the smoke detection system in accordance with NFPA 72. .This deficient practice may prevent the prompt initiating of smoke detectors alerting the residents and staff to smoke products due to the devices being out of calibration, affecting 1 of 6 smoke zones. The facility has capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM it is observed there is a smoke detector hanging by it's wires from the ceiling in the Front Lobby Air Handling Mechanical room.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow nor closer than 3 feet from an air supply or return. 1999 NFPA 72, 2-3.5.1

Based on observation and staff interview, the facility failed to assure that sprinklers are properly maintained and clear of obstructions. The deficient practice fails to ensure the required sprinkler coverage in the event of a fire, affecting 6 of the 6 smoke zones. The facility has a capacity of 25 with a census of 21.

Findings Include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) There are two PIV's (post indicator valves) and neither is pad locked by the Ambulance bay.
--2) There is spray-on fire coating on sprinkler pipes in the Basement.
--3) There are no weekly checks being completed on the Dry sprinkler system.
--4) There is a metal cabinet within 18" of a sprinkler in the IT Storage/Elevator Mechanical room in the Library basement.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Unacceptable obstructions to spray patterns shall be corrected. 1998 NFPA 25, 2-2.1.2

Based on observation and staff interview the facility failed to ensure that portable fire extinguishers are not obstructed for immediate use. This deficient practice may prevent the portable fire extinguisher from being readily accessible due to difficulty in retrieving in an emergency situation, affecting 1 of 6 smoke zones. The facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM it is observed there is a fire extinguisher obstructed from view with a tall metal cabinet in the Library basement by the Boiler room door.

Maintenance Staff A was present and acknowledged the finding.

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 assure that the smoking area has the proper container with a self-closing lid. This deficient practice fails to ensure that the ashtrays are not being dumped into trash receptacles with other combustibles, increasing the risk of fire, affecting 1 of 6 smoke zones. The facility has a capacity of 25 and a census of 21.

Findings Include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM it is observed there is no metal container with a self closing lid to dispose of cigarette butts from the ash trays in the smoking area outside of ER by the generator.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Smoking regulations shall include: Smoking shall be prohibited in any room or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. Smoking by patients classified as not responsible shall be prohibited unless under direct supervision. Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted and metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 2000 NFPA 101, 18/19.7.4

Based upon observation, record review and staff interview the facility could not produce documentation indicating proper maintenance for the kitchen hood heat removal system as required by NFPA 96 "Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations ". Failure to clean these portions of the hood vapor removal system could cause a fire, affecting 1 of 6 smoke zones including the Dining room. The facility has a capacity of 25 and a census of 21.

Finding Include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM it is observed there has been no cleaning of the Kitchen hood flue by an outside vendor since installation of the hood one year ago.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s). 1998 NFPA 96, 8-3.1

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 2 of 6 smoke zones. This facility has a capacity of 25 with a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) There is storage of eight (8) wheeled carts, fans, paint cans, bed pads, scaffolding, bed side tables, boxes of isolation suits, shelving and a work bench in the Housekeeping basement exit corridor.
--2) There is storage of a metal filing cabinet for employee mail, a computer and a food cart stored in the Time Clock exit corridor. This was cited during the 2008 survey.
--3) There is rack storing flammable linens in the Surgery exit corridor by OR 3.

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, staff interview and record review, the facility did not assure smoke dampers located in smoke barrier walls and ventilation ducts are operable to prevent the passage of smoke and fire to another smoke zone. This deficient practice effects 6 of 6 smoke zones. This facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) There is no documentation the dampers have ever been tested.
--2) There is ventilation ducts and neither surveyor or maintenance can confirm if there is a damper in the two ventilation ducts in the basement Air Filter storage room.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: An approved damper designed to resist the passage of smoke shall be provided for each air transfer opening or duct penetration of a required smoke barrier per NFPA 101, 8.3.5.1. Required smoke dampers in air transfer openings shall close upon detection of smoke by approved smoke detectors in accordance with 1999 NFPA 72 and 2000 NFPA 101, 8.3.5.3

NFPA Standard: Ceiling dampers or other methods of protecting openings in rated floor- or roof-ceiling assemblies shall comply with the construction details of the tested floor- or roof-ceiling assembly or with listed ceiling air diffusers or listed ceiling dampers. Ceiling dampers shall be tested in accordance with UL 555C, Standard for Safety Ceiling Dampers. 1999 NFPA 90A, 3-4.4

Based on record review and staff interview, the facility fails to properly document testing and maintenance of the generator in accordance with NFPA 99 and NFPA 110. The deficient practice potentially reduces the reliability of the generator. The deficient practice affects 6 of 6 smoke zones. The facility has a capacity of 25 with a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM it is observed there is no annual generator maintenance documentation available to surveyors.

Maintenance Staff A was present and acknowledged the finding. Maintenance Staff A stated the annual generator maintenance was completed in June '12, but no documentation is available.

NFPA Standard: Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1

Based on observation and staff interview the facility failed to assure that electrical equipment is properly maintained and installed in accordance with NFPA 70, National Electric Code. This deficient practice could cause an electrical failure or fire, affecting 6 out of 6 smoke zones. The facility has a capacity of 25 with a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) There are four (4) open junction boxes in the Boiler room.
--2) There is an extension cord plugged into another extension cord attached to the Front Canopy.
--3) There is an open junction box above the ceiling tiles of the Pink Ladies storage closet.
--4) There is a power strip not secured in the Acute Med room.
--5) There is an open junction box above the ceiling tiles in the Comm room across from 115.
--6) There is storage within 3 ft of electrical panels in the Electrical room across form 120.
--7) There is a microwave plugged into a power strip, where the strip runs from the sink area to the microwave, there is no GFCI outlet at the sink in Raspatory Therapy 231.
--8) There is an open junction box in Bio Hazard storage.
--9) There is a broken electrical outlet cover in the Boiler room.
--10) There is an open junction box in room 3 of the Old 400 Basement.
--11) There is an open junction box sitting on top of a run off water storage tank that is not mounted in the Old 400 Basement.
--12) There is an open outlet box that is not attached to the wall above the ceiling tiles at the 2 hour wall between LTCU and hospital - hospital side of wall.
--13) There is an open junction box above the ceiling tiles in the exit corridor of the Main hospital exit corridor by the Time Clock exit.
--14) There is an open junction box above the ceiling tiles at the 2 hour wall into the New Patient wing -west side of doors.
--15) There is an open junction box on the patient side of the 2 hour wall by room 123.
--16) There is an unsecured electrical outlet box above the ceiling tiles in the New Patient wing, North side of the 2 hour wall by the Doctor's exit.
--17) There is an open junction box above the ceiling tiles by room 407.
--18) There is an open junction box above the ceiling tiles across Surgery at the smoke doors across from room OR 3.
--19) There are two (2) open junction boxes above the ceiling tiles at the 2 hour wall, ER side of wall by the Boiler room.

Maintenance Staff A was present and acknowledged the finding.


NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8


NFPA Standard: All energized distribution panels/components shall be provided with protective covers that keep personnel separated from live electrical components. NFPA 70, 1999 ed

Based on observation, record review and staff interview, the facility is not assuring that the elevators are inspected which could result in failure of an elevator. This deficient practice affects 4 of 6 smoke zones. The facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) The last available elevator inspection documentation is dated 2007. The facility is 5 years past due for the elevator inspection.
--2) There is storage of an excessive amount of computer wires on the floor next to the elevator control unit in the Basement Elevator Mechanical room.
--3) There is a large storage room where an elevator control unit is located. Inside this storage room is combustible storage of numerous shelfves of patient records, kitchen storage, barrells of discarded X-rays and IT storage in the Elevator Mechanical Equipment room in the Old Morgue in the Library Basement.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4.
9.4.3.1 2000 NFPA 101, 19.5.3

Based on observation and staff interview, the facility fails to assure alcohol based hand rub containers are not installed above or adjacent to an ignition source. This deficient practice could result in a fire by failing to ensure that the ABHS does not come into contact with an ignition source, affecting occupants in 1 of 6 smoke zones. The facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM it is observed there is an alcohol gel container attached to the wall above the light switch in the Basement Materials Management area.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Dispensers shall not be installed in a corridor that is under 6 feet wide; the maximum dispenser capacity for rooms, corridors and areas open to the corridor is 1.2 liters (2.0 liters in suites of rooms); the minimum horizontal spacing shall be 4 feet; not more than 37.8 liters shall be mounted within a smoke compartment; storage of quantities greater than 5 gallons (18.9 liters) in a single smoke compartment shall meet the requirements of NFPA 30; dispensers installed directly over carpeted surfaces shall be permitted only in sprinklered smoke compartments; and the dispensers shall not be installed over or directly adjacent to an ignition source. Centers for Medicare & Medicaid Services, 42 CFR Parts 403, 416, 418, 460, 482, 483, and 485, [CMS-3145-IFC], RIN 0938-AN36, Medicare and Medicaid Programs; Fire Safety Requirements Federal Register, Vol. 70, No. 57, Friday, March 25, 2005 42 CFR 483.70 (a) (7)

Based on observation and staff interviews, the facility failed to assure that the 2 hour wall is sealed, failing to provide the proper fire resistance rating. This affects 4 of the 6 smoke zones. The facility has a capacity of 25 with a census of 21.

Findings Include:

During the tour on 7/12/12 and 7/16/12 between 10:30 am and 6:00 pm the following is observed:

--1) There is a gap around a conduit in the 2 hour wall between the LTCU and hospital - hospital side of wall.
--2) There are gaps around conduits, three (3) open wire chase X 2 sides, and a white foam type product filling in a penetration at the top of the 2 hour wall of the New Patient wing at the SE smoke wall.
--3) There is an open wire chase with gaps around this wire chase in the 2 hour wall on new Patient wing by room 123.
--4) The fire barrier doors are not latching with the provided latching hardware in the 2 hour wall by room 123.

Maintenance Staff A was present and acknowledged the finding. Maintenance Staff A stated there is no documentation for the white foam type product.

NFPA Standard: 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. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self-closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2

Based on observation and staff interview, the facility is not providing appropriate construction standards as required by the life safety code and a rated ceiling assembly is not provided as required by the building's construction type, which would prevent containment of smoke and/or fire, affecting 2 of 6 smoke zones. The facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) There are gaps around metal framing on the North wall of the Front Lobby Mechanical room.
--2) There are ceiling tiles out in the Front Lobby Mechanical room.
--3) There are ceiling tiles out in the Pink Ladies storage closet.
--3) There is expansion foam used to seal gaps on the upper wall of the IT Education room.

Staff A was present and acknowledged the findings.

NFPA Standard: Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2 per NFPA 101, 8.2.3.1.1. Space between wires and similar building service equipment that pass through fire barriers shall be protected by filling the space with a material that is capable of maintaining the fire resistance of the fire barrier or shall be protected by an approved device that is designed for the specific purpose 2000 NFPA 101, 8.2.3.2.4.2

Based on observation, the facility failed to maintain corridor walls with a fire resistance rating of not less than 1/2 hour and that were smoke resistive. The deficient practice affected 1 of 6 smoke zones. The facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/17 between 10:30 AM and 6:00 PM it is observed there is expansion foam filling penetrations in the non-sprinkled 400 hall exit corridor on both sides of the hall above the ceiling tiles. This deficiency was also cited during the 2008 survey.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, and shall have a fire resistance rating of not less than 1/2 hour. Exception: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system, a corridor shall be permitted to be separated from all other areas by non-rated partitions and terminate at the ceiling if the ceiling is constructed to limit the transfer of smoke. Exception: Existing corridor partitions shall be permitted to terminate at ceilings that are not an integral part of a floor construction if 5 ft or more of space exists between the top of the ceiling subsystem and the bottom of the floor or roof above, provided that the ceiling is a fire-rated assembly tested to have a fire resistance rating of not less than 1 hour in compliance with the provisions of 8.2.3.1. 2000 NFPA 101, 19.3.6.2

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 3 of 6 smoke zones. The facility has a capacity of 25 with a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) The self closing door is blocked open with a wooden wedge to Basement Housekeeping. This was corrected at time of survey.
--2) The self closing device is not latching the door to the door frame to Surgery Staff Lounge.
--3) The self closer is not latching the door to the door frame to X-Ray B.
--4) There is no latching hardware on the corridor door to IT Education room. The door does have a push button type lock on the door.
--5) The self closing door is not latching to the door frame to the exit stairwell in the Basement that leads to ER.

Maintenance Staff A was present and acknowledged the finding.

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 smoke barriers are 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 6 smoke zones. This facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) There are gaps around wires in the ER smoke wall, East side of wall by the North double doors.
--2) There are gaps around a pipe, conduits and wires on both sides of the ER smoke wall by the Boiler room.

Maintenance Staff A was present and acknowledged the finding.

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 2 of 6 smoke zones. This facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) The self closer is not latching to the basement Air Filter storage room.
--2) The self closer is not latching to the Surgery Storage room by OR 3.
--3) There is ceiling tiles out of place in the Sterilizer Boiler room.

Maintenance Staff A was present and acknowledged the finding.

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, the facility failed to provide means of egress that are maintained free of all obstructions or impediments to a full instant use in case of fire or other emergency. The deficient practice prevents exits from being arranged so that they are readily available and accessible, affecting 2 of 6 smoke zones. This facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) The emergency exit placard is showing a stairwell as an exit stairwell, which is not an exit in the South basement.
--2) There is old hospital furniture obstructing the exit access in the Old 400 Basement, exit leads into the enclosed courtyard.

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 fails to assure there is normal illumination in all exit corridors, failing to ensure that all areas of egress will not be left in total darkness. This deficient practice affects 5 of 6 smoke zones. The facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) There is no two bulb light fixture out of the Doctors North exit.
--2) The overhead lights can be turned off with a manual switch in the Surgery West exit stairwell.
--3) There is one light fixture connected to the generator in the Library exit corridor, all other lights can be turned off with a manual switch.
--4) The overhead lights can be turned off with a manual switch in the Time Clock exit corridor.
--5) The overhead lights in the nurse work station can be turned off with a manual switch in Surgery.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4

Based on observation and staff interview the facility fails to assure directional and exit signs are properly displayed. This deficient practice fails to direct occupants to a safe path of egress in case of an emergency, affecting 1 of 6 smoke zones. The facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM it is observed there is an exit sign that directs exiting from the Old 400 Basement Storage room into the 2002 Basement Storage room.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent. 2000 NFPA 101, 7.10.2

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency affecting 6 of 6 smoke zones. The facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM it is observed the fire drill scenarios are incomplete records. The scenarios do not reflect a possible "fire scenario", rather how many staff brought fire extinguishers to the fire zone.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based on record review and staff interview, the facility failed to assure that the fire alarm system required for life safety is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. This deficiency fails to ensure that the fire alarm system control functions are working properly jeopardizing the safety of all building occupants. This deficiency would affect 6 of 6 smoke zones. This facility has a capacity 25 with a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) The last annual fire alarm inspection report available to surveyors is dated Feb 2011. The facility is five (5) months past due for the annual inspection.
--2) There is a smoke detector hanging by it's wires from the ceiling in the Front Lobby Air Handling Mechanical room.
--3) The fire alarm panel (FAP) is obstructed for immediate use with blue computer wires hanging in front of the panel. The fire alarm panel door cannot close due to the wires obstructing the panel door.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2. 1999 NFPA 72, 7-2.2

NFPA Standard: Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of the code, such device, equipment, system, condition, arrangement, level of protection, or any other feature shall thereafter be maintained unless the Code exempts such maintenance. 2000 NFPA 101, 4.5.7

Based on record review and staff interview, the facility failed to maintain the smoke detection system in accordance with NFPA 72. .This deficient practice may prevent the prompt initiating of smoke detectors alerting the residents and staff to smoke products due to the devices being out of calibration, affecting 1 of 6 smoke zones. The facility has capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM it is observed there is a smoke detector hanging by it's wires from the ceiling in the Front Lobby Air Handling Mechanical room.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow nor closer than 3 feet from an air supply or return. 1999 NFPA 72, 2-3.5.1

Based on observation and staff interview, the facility failed to assure that sprinklers are properly maintained and clear of obstructions. The deficient practice fails to ensure the required sprinkler coverage in the event of a fire, affecting 6 of the 6 smoke zones. The facility has a capacity of 25 with a census of 21.

Findings Include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) There are two PIV's (post indicator valves) and neither is pad locked by the Ambulance bay.
--2) There is spray-on fire coating on sprinkler pipes in the Basement.
--3) There are no weekly checks being completed on the Dry sprinkler system.
--4) There is a metal cabinet within 18" of a sprinkler in the IT Storage/Elevator Mechanical room in the Library basement.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Unacceptable obstructions to spray patterns shall be corrected. 1998 NFPA 25, 2-2.1.2

Based on observation and staff interview the facility failed to ensure that portable fire extinguishers are not obstructed for immediate use. This deficient practice may prevent the portable fire extinguisher from being readily accessible due to difficulty in retrieving in an emergency situation, affecting 1 of 6 smoke zones. The facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM it is observed there is a fire extinguisher obstructed from view with a tall metal cabinet in the Library basement by the Boiler room door.

Maintenance Staff A was present and acknowledged the finding.

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 assure that the smoking area has the proper container with a self-closing lid. This deficient practice fails to ensure that the ashtrays are not being dumped into trash receptacles with other combustibles, increasing the risk of fire, affecting 1 of 6 smoke zones. The facility has a capacity of 25 and a census of 21.

Findings Include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM it is observed there is no metal container with a self closing lid to dispose of cigarette butts from the ash trays in the smoking area outside of ER by the generator.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Smoking regulations shall include: Smoking shall be prohibited in any room or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. Smoking by patients classified as not responsible shall be prohibited unless under direct supervision. Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted and metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 2000 NFPA 101, 18/19.7.4

Based upon observation, record review and staff interview the facility could not produce documentation indicating proper maintenance for the kitchen hood heat removal system as required by NFPA 96 "Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations ". Failure to clean these portions of the hood vapor removal system could cause a fire, affecting 1 of 6 smoke zones including the Dining room. The facility has a capacity of 25 and a census of 21.

Finding Include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM it is observed there has been no cleaning of the Kitchen hood flue by an outside vendor since installation of the hood one year ago.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s). 1998 NFPA 96, 8-3.1

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 2 of 6 smoke zones. This facility has a capacity of 25 with a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) There is storage of eight (8) wheeled carts, fans, paint cans, bed pads, scaffolding, bed side tables, boxes of isolation suits, shelving and a work bench in the Housekeeping basement exit corridor.
--2) There is storage of a metal filing cabinet for employee mail, a computer and a food cart stored in the Time Clock exit corridor. This was cited during the 2008 survey.
--3) There is rack storing flammable linens in the Surgery exit corridor by OR 3.

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, staff interview and record review, the facility did not assure smoke dampers located in smoke barrier walls and ventilation ducts are operable to prevent the passage of smoke and fire to another smoke zone. This deficient practice effects 6 of 6 smoke zones. This facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) There is no documentation the dampers have ever been tested.
--2) There is ventilation ducts and neither surveyor or maintenance can confirm if there is a damper in the two ventilation ducts in the basement Air Filter storage room.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: An approved damper designed to resist the passage of smoke shall be provided for each air transfer opening or duct penetration of a required smoke barrier per NFPA 101, 8.3.5.1. Required smoke dampers in air transfer openings shall close upon detection of smoke by approved smoke detectors in accordance with 1999 NFPA 72 and 2000 NFPA 101, 8.3.5.3

NFPA Standard: Ceiling dampers or other methods of protecting openings in rated floor- or roof-ceiling assemblies shall comply with the construction details of the tested floor- or roof-ceiling assembly or with listed ceiling air diffusers or listed ceiling dampers. Ceiling dampers shall be tested in accordance with UL 555C, Standard for Safety Ceiling Dampers. 1999 NFPA 90A, 3-4.4

Based on record review and staff interview, the facility fails to properly document testing and maintenance of the generator in accordance with NFPA 99 and NFPA 110. The deficient practice potentially reduces the reliability of the generator. The deficient practice affects 6 of 6 smoke zones. The facility has a capacity of 25 with a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM it is observed there is no annual generator maintenance documentation available to surveyors.

Maintenance Staff A was present and acknowledged the finding. Maintenance Staff A stated the annual generator maintenance was completed in June '12, but no documentation is available.

NFPA Standard: Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1

Based on observation and staff interview the facility failed to assure that electrical equipment is properly maintained and installed in accordance with NFPA 70, National Electric Code. This deficient practice could cause an electrical failure or fire, affecting 6 out of 6 smoke zones. The facility has a capacity of 25 with a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) There are four (4) open junction boxes in the Boiler room.
--2) There is an extension cord plugged into another extension cord attached to the Front Canopy.
--3) There is an open junction box above the ceiling tiles of the Pink Ladies storage closet.
--4) There is a power strip not secured in the Acute Med room.
--5) There is an open junction box above the ceiling tiles in the Comm room across from 115.
--6) There is storage within 3 ft of electrical panels in the Electrical room across form 120.
--7) There is a microwave plugged into a power strip, where the strip runs from the sink area to the microwave, there is no GFCI outlet at the sink in Raspatory Therapy 231.
--8) There is an open junction box in Bio Hazard storage.
--9) There is a broken electrical outlet cover in the Boiler room.
--10) There is an open junction box in room 3 of the Old 400 Basement.
--11) There is an open junction box sitting on top of a run off water storage tank that is not mounted in the Old 400 Basement.
--12) There is an open outlet box that is not attached to the wall above the ceiling tiles at the 2 hour wall between LTCU and hospital - hospital side of wall.
--13) There is an open junction box above the ceiling tiles in the exit corridor of the Main hospital exit corridor by the Time Clock exit.
--14) There is an open junction box above the ceiling tiles at the 2 hour wall into the New Patient wing -west side of doors.
--15) There is an open junction box on the patient side of the 2 hour wall by room 123.
--16) There is an unsecured electrical outlet box above the ceiling tiles in the New Patient wing, North side of the 2 hour wall by the Doctor's exit.
--17) There is an open junction box above the ceiling tiles by room 407.
--18) There is an open junction box above the ceiling tiles across Surgery at the smoke doors across from room OR 3.
--19) There are two (2) open junction boxes above the ceiling tiles at the 2 hour wall, ER side of wall by the Boiler room.

Maintenance Staff A was present and acknowledged the finding.


NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8


NFPA Standard: All energized distribution panels/components shall be provided with protective covers that keep personnel separated from live electrical components. NFPA 70, 1999 ed

Based on observation, record review and staff interview, the facility is not assuring that the elevators are inspected which could result in failure of an elevator. This deficient practice affects 4 of 6 smoke zones. The facility has a capacity of 25 and a census of 21.

Findings include:

During the tour on 7/12/12 and 7/16/12 between 10:30 AM and 6:00 PM the following is observed:

--1) The last available elevator inspection documentation is dated 2007. The facility is 5 years past due for the elevator inspection.
--2) There is storage of an excessive amount of computer wires on the floor next to the elevator control unit in the Basement Elevator Mechanical room.
--3) There is a large storage room where an elevator control unit is located. Inside this storage room is combustible storage of numerous shelfves of patient records, kitchen storage, barrells of discarded X-rays and IT storage in the Elevator Mechanical Equipment room in the Old Morgue in the Library Basement.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4.
9.4.3.1 2000 NFPA 101, 19.5.3