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Based on observation and staff interview, the facility failed to ensure that corridor doors fit tightly within the doorframe to resist the passage of smoke. This deficient practice affects occupants in two of two smoke zones on the patient room floor, and one of two smoke zones on the first floor as the doors would not prevent the spread of fire and smoke. This facility has a capacity of 63 and a census of 45 patients.
Findings are:

1. Observation on 3/23/11 at 12:48 pm revealed the corridor door to Room 212 contained a greater than ? inch distance between the face of the door and the door stop. The door appeared to be warped.

2. Observation on 3/23/11 at 1:41 pm revealed the corridor door to Room 102 obstructed by a scaled.

3. Observation on 3/23/11 at 2:40 pm revealed the corridor door to Room 11 failed to be smoke tight around the edges. The door appeared to be warped.

4. Observation on 4/4/11 at 2:30 pm revealed the sliding glass doors to the rooms by the Laboratory failed to be smoke tight. Closer examination revealed the doors consisted of three panels that slide to close, one of the panels had failed to remain in it ' s track on two of the doors.

All observations were confirmed by Maintenance A at the times of the observations.

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 shall be provided with positive latching hardware. 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 interview the facility failed to provide an unobstructed exit from the MOB hospital space affecting two floors of the building.
Findings are:

Observation on 3/23/11 at 2:50 pm revealed the outside exit doors from the second floor of the MOB building were obstructed by the doors from the first floor corridor. The leaf of the west door obstructed approximately ? of the west exit door. Maintenance A confirmed the obstruction at the time of the observation.

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 interview the facility failed to provide a two-hour fire resistance rating in the two hour wall between the MOB and the hospital. This would allow the passage of smoke from one smoke zone to another, affecting all occupants in one of two smoke compartments. This facility has a capacity of 63 and a census of 45 patients.
Findings are:

Observation on 3/25/11 at 3:17 pm revealed the lack of latching of the two doors in the two hour wall to the MOB building. Closer examination revealed the latching mechanisms were held in the retracted locked position so as not to function. The doors were on a automatic push button for opening going into the link to the MOB.

Interview with Director of Clinical Services confirmed the lack of latching in these doors and could not verify if the doors latch automatically with the activation of the fire alarm, sprinkler system and/or loss of power, at the time of the observations.

NFPA Standard: Fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground. (See also 8.2.3.)
Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) * Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
(b) 19.2.2.2.6*
Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility. 2000 NFPA 101 7.2.4.3.1; 19.2.2.2.6
Fire Exit Hardware. Labeled devices for swinging fire doors installed to facilitate safe egress of persons and generally consisting of a cross bar and various types of latch mechanisms that cannot hold the latch in a retracted locked position. NFPA 80

Based on observation and interview, the facility failed to provide a remote alarm for the emergency generator at a work site readily observable by personnel. The deficient practice would affect all three levels of the building, all patients and staff. The facility has the capacity for 63 beds and a census of 45 the day of survey.
Findings are:

Observation on 3/23/11 at 8:25 am revealed the facility's emergency power supply (EPS) consisted of a generator located outside the building and a transfer switch panel located in a mechanical room. The remote annunciator for the generator location was not a continuously occupied location monitored by staff as it was located in the lower level maintenance office. The facility failed to provide an audible annunciator that provided an audible alarm for the emergency generator that is in a work site readily observable by personnel. Interview on 3/23/11 at 8:25 am with the Maintenance A revealed that the maintenance office was not a continuously occupied place as the maintenance department was not always in the office area.

NFPA Standard: A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2] 1999 NFPA 99 3-4.1.1.15

Based on observation and staff interview, the facility failed to ensure that corridor doors fit tightly within the doorframe to resist the passage of smoke. This deficient practice affects occupants in two of two smoke zones on the patient room floor, and one of two smoke zones on the first floor as the doors would not prevent the spread of fire and smoke. This facility has a capacity of 63 and a census of 45 patients.
Findings are:

1. Observation on 3/23/11 at 12:48 pm revealed the corridor door to Room 212 contained a greater than ? inch distance between the face of the door and the door stop. The door appeared to be warped.

2. Observation on 3/23/11 at 1:41 pm revealed the corridor door to Room 102 obstructed by a scaled.

3. Observation on 3/23/11 at 2:40 pm revealed the corridor door to Room 11 failed to be smoke tight around the edges. The door appeared to be warped.

4. Observation on 4/4/11 at 2:30 pm revealed the sliding glass doors to the rooms by the Laboratory failed to be smoke tight. Closer examination revealed the doors consisted of three panels that slide to close, one of the panels had failed to remain in it ' s track on two of the doors.

All observations were confirmed by Maintenance A at the times of the observations.

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 shall be provided with positive latching hardware. 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 interview the facility failed to provide an unobstructed exit from the MOB hospital space affecting two floors of the building.
Findings are:

Observation on 3/23/11 at 2:50 pm revealed the outside exit doors from the second floor of the MOB building were obstructed by the doors from the first floor corridor. The leaf of the west door obstructed approximately ? of the west exit door. Maintenance A confirmed the obstruction at the time of the observation.

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 interview the facility failed to provide a two-hour fire resistance rating in the two hour wall between the MOB and the hospital. This would allow the passage of smoke from one smoke zone to another, affecting all occupants in one of two smoke compartments. This facility has a capacity of 63 and a census of 45 patients.
Findings are:

Observation on 3/25/11 at 3:17 pm revealed the lack of latching of the two doors in the two hour wall to the MOB building. Closer examination revealed the latching mechanisms were held in the retracted locked position so as not to function. The doors were on a automatic push button for opening going into the link to the MOB.

Interview with Director of Clinical Services confirmed the lack of latching in these doors and could not verify if the doors latch automatically with the activation of the fire alarm, sprinkler system and/or loss of power, at the time of the observations.

NFPA Standard: Fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground. (See also 8.2.3.)
Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) * Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
(b) 19.2.2.2.6*
Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility. 2000 NFPA 101 7.2.4.3.1; 19.2.2.2.6
Fire Exit Hardware. Labeled devices for swinging fire doors installed to facilitate safe egress of persons and generally consisting of a cross bar and various types of latch mechanisms that cannot hold the latch in a retracted locked position. NFPA 80

Based on observation and interview, the facility failed to provide a remote alarm for the emergency generator at a work site readily observable by personnel. The deficient practice would affect all three levels of the building, all patients and staff. The facility has the capacity for 63 beds and a census of 45 the day of survey.
Findings are:

Observation on 3/23/11 at 8:25 am revealed the facility's emergency power supply (EPS) consisted of a generator located outside the building and a transfer switch panel located in a mechanical room. The remote annunciator for the generator location was not a continuously occupied location monitored by staff as it was located in the lower level maintenance office. The facility failed to provide an audible annunciator that provided an audible alarm for the emergency generator that is in a work site readily observable by personnel. Interview on 3/23/11 at 8:25 am with the Maintenance A revealed that the maintenance office was not a continuously occupied place as the maintenance department was not always in the office area.

NFPA Standard: A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2] 1999 NFPA 99 3-4.1.1.15