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Based on observation and interview, the facility did not maintain corridors as required.
Finding include:
On 1/11/2011 at 1:40pm, two doors between the corridor and kitchen doors were found not to latch. The facility engineer acknowledged the findings.

Corridor doors that do not latch subject residents to increased death and injury due to fire.

Based on observation and interview, the facility did not maintain vertical openings as required.

Findings include:
On 1/11/2011 at 2:15 pm the sprinkler nearest the fixed windows on the 2nd floor between the elevator lobby and the atrium was found to be approximately 4 feet from the glass. The sprinkler nearest the windows on the 2nd floor between the pre op waiting room and the atrium was found to be 5 feet from the glass. Sprinkler are required to be within 1 foot of the glass. The facility engineer acknowledge the findings.

Improperly protected vertical openings increase the risk of death or injury due to fire.

Ref: 2000 NFPA 101, Section 8.2.5.6, Exception no. 2
Exception No. 2:* Glass walls and inoperable windows shall be permitted in lieu of the fire barriers where automatic sprinklers are spaced along both sides of the glass wall and the inoperable window at intervals not to exceed 6 ft (1.8 m). The automatic sprinklers shall be located at a distance from the glass not to exceed 1 ft (0.3 m) and shall be arranged so that the entire surface of the glass is wet upon operation of the sprinklers. The glass shall be tempered, wired, or laminated glass held in place by a gasket system that allows the glass framing system to deflect without breaking (loading) the glass before the sprinklers operate. Automatic sprinklers shall not be required on the atrium side of the
glass wall and the inoperable windows where there is no walkway or other floor area on the atrium side above the main floor level. Doors in such walls shall be glass or other material that resists the passage of smoke. Doors shall be self-closing or automatic-closing upon detection of smoke.

Based on observation and interview, the facility did not provide exit signs as required.

Findings include:
On 1/11/2011 at 1:00pm, the pharmacy was found to have a main room where there the doors leading to the exits were not obvious. The facility engineer confirmed the findings.

Inadequate exit signs increase the risk of death or injury due to fire.

Ref: 2000 NFPA 101 Section
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.
Exception: Where the path of egress travel is obvious, signs shall not be required in one-story buildings with an occupant load of fewer than 30 persons.

Based on observation and interview, smoke barriers were not maintained as required.

Findings include:
On 1/11/2011 at 2:55pm, a 2 " conduit viewed from room 2A145 with telecom wires was unsealed around its exterior perimeter and within the conduit.

On 1/11/2011 at 3:00pm the smoke barrier viewed above the ceiling tile in room 149 was un sealed at conduit/ pipe penetrations.

The findings were confirmed by the facility engineering staff at the time of the discovery.

Unsealed smoke barrier penetrations increase the risk of injury or death due to smoke and fire.

Ref: 2000 NFPA 101 Section 19.3.7.3: Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Based on observation and interview, the facility did not maintain hazardous areas as required.

Findings include:
On 1/11/2011 at 11:15am, the laboratory hazardous storage area was blocked open with a cabinet. The facility engineer confirmed the finding. The cabinet was removed. The lab staff indicated that the door was open due to a malfunctioning cooling unit. No interim life safety measures were in place.

On 1/11/2011 at 1:50pm the double doors to the property and supply area to the corridor were held open by magnetic hold open devices. When the doors were released, the doors were held ajar by the astragal.

On 1/11/2011 at 2:00pm, doors from the supply area leading to exit stairwell B were propped open with kick down devices.

The facility engineer acknowledged the findings at the time of discovery.

Hazardous area doors that are propped open or do not close completely increase the risk of injury or death due to fire from fires originating in the hazardous area.

Based on observation and interview, the facility did not maintain stair way signs.

Findings include:

On 1/11/2011 at 9:45 am, stairwell b signs were found to be missing letters. Although stairway signs are only required in buildings of 5 or more stories, life safety features obvious to the public if not required by the code must be maintained or removed.

Faulty life safety features increase the risk of death or injury when depended upon during a fire.

Ref: 2000 NFPA 101 Sections
4.6.12.2* Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

19.2.2.3 Stairs. Stairs complying with 7.2.2 shall be permitted.
7.2.2.5.4 Stairwell signs

Based on observation and interview, the facility did not maintain exits as required.

Findings include:
On 1/11/2011 at 11:30am, the door between radiology and emergency room had a deadbolt lock mounted at a height of approximately 60inches. An exit sign was mounted above the door to egress from radiology to the Emergency room on the radiology side. The thumb screw was on the egress sign side of the door as required. In addition, the deadbolt in combination with the door knob required more than one releasing operation. The facility engineer acknowledged the finding.

The maximum mounting height for locks is 48 " in the means of egress.

Ref: 2000 NFPA 101 Section
7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

On 1/11/2011 at 8:00 am, the landing in the central stairway at the basement level was found to be used as a storage area. A fenced area was found to be storing tables and miscellaneous items. The facility engineer acknowledged the finding and had the area cleared before the end of the survey.

Exit stairways are required to be free of any material not essential to the function of the stairway. Stairwell storage increases the risk of death of injury due to fire as these items could obstruct the use of the egress function and increase the risk of fire in the stairwell.

19.2.1 Ref: Chapter 7
7.1.3.2.3 Sterile exit enclosure requirement, no storage

Improperly maintained means of egress increase the risk of death or injury due to fire.

Based on records review and interview, the facility did not maintain the fire alarm system as required.

Findings include:

On 1/11/2011 at 3:30, review of fire alarm testing records indicated testing only occurred on an annual basis. Inspection of the batteries indicated that they were sealed lead acid batteries. Sealed lead acid batteries require semiannual load voltage testing. Semiannual valve tamper switch testing was also missing. The findings were acknowledged by the facility engineer.
Inadequate testing of fire alarm systems increases the risk of death and injury due to fire.

Ref: 2000 NFPA 101 Section
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.
Ref: 1999 NFPA 72 Table 7-3.2

Based on observation and interview, the facility did not provide complete or maintain sprinkler coverage as required.

Findings include:
On 1/11/2011 at 10:00 am, sprinklers could not be located in two of two operating rooms. The facility engineer could not provide an explanation. Facilities that operate as fully sprinkled facilities and have unsprinkled areas or impaired sprinklers increase the risk of death or injury due to fire.

On 1/11/2011 at 2:10 storage in room 200 was found to be within 14 " of the sprinkler head deflector. The facility engineer confirmed the finding. 18 inches of clearance below sprinkler heads is required to allow for spray pattern development. Obstructed sprinkler heads increase the risk of death and injury due to fire if extinguishment is impaired due to storage.

On 1/11/2011 at 2:20, a plastic guard was found on a sprinkler head in room 1B131 used as an electrical closet. Plastic guards will impair the function of a sprinkler increasing the risk of death or injury due to a fire.

The facility engineer acknowledged the findings at the time of discovery.

This facility is not required to have a sprinkler system, but operates and takes advantage of allowances as a fully sprinkled facility. As such, full sprinkler coverage is required.


Ref: 2000 NFPA 13
Section 5-5.6* Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 in. (457 m) or greater.

Based on records review and interview, the facility was found to not test the fire sprinkler system as required.

Findings include:

On 1/11/2011 at 3:30pm, testing records review indicated that only annual testing occurred. Water flow devices and not been tested quarterly as required.

Inadequate testing of the sprinkler system increases the risk of death and injury due to a fire.

The facility engineer acknowledged the findings at the time of discovery.

Ref: 2000 NFPA 101 Section
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
Ref: 1999 NFPA 25, Section 2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, Mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
Table 2-1 Alarm Devices- quarterly
Main Drain- annual
Antifreeze- annual
Gauges- 5 years
Fast response Sprinklers- 20 years and 10 thereafter
Sprinklers- 50 years and 10 thereafter

Based on record review and interview, the facility did not maintain cooking facilities as required.

Findings include:

On 1/11/2011 at 3:30pm records review indicated that the hood was not inspected annually as required for facilities with low volume cooking operations. In addition the entire exhaust system was not ever cleaned.

The findings were acknowledged by the facility engineer at the time of discovery.

Inadequately maintained cooking facilities increase the risk of death and injury due to fire.

Ref: 2000 NFPA 101 Section
19.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3.
9.2.3 Ref: NFPA 96

Ref: 1998 NFPA 96 Section
8-3.1 Annual exhaust system inspection for cleaning for low volume cooking volume
8-3.1.1 Cleaning requirements

Based on interview and records review, the facility did not maintain medical gas systems as required.

Findings include:
On 1/10/2011 at 4:45 pm the 2010 annual med gas report inspection report identified various upgrades needed to meet NFPA 99 requirements required redundant equipment and items to facilitate maintenance were reported to be incomplete.

The facility engineer estimated that 6 additional months would be needed to correct the deficient items.

The items identified as deficient in the report increase the risk of death or injury due to medical gas malfunctions.