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42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The building construction type was non-compliant, specific findings include: There are penetrations in the corridor wall (two) new tower 1st floor ed/x-ray entrance hall in order to maintain the required rating of the wall.

Reference NFPA 101, 18.1.6.2, 18.1.6.3, 18.2.5.1
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The building construction type was non-compliant, specific findings include: The one hour corridor wall to the Lab Shell space located at the double door and HR is not sealed conduit penetrations at the top of the wall in order to maintain the required fire resistance rating of the wall. Location: Old Tower lower level, near HR

Reference NFPA 101, 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.70(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The corridor doors were non-compliant, specific findings include:
1) Roller latches were used in the following areas:
a) Old tower 2nd floor - Vance Granville Community Hospital classroom, VGCH, room 2008 and adjacent computer room.
b) Old tower 3rd floor near room 344
2) There was a Dutch door that the upper leaf was not equipped with a latching device nor a astragal, rabbet or bevel. Location: old tower 1st floor - infection control


Reference NFPA 101, 19.3.6.3.1 Roller latches are prohibited by CMS regulations in all health care facilities. Reference NFPA 101 19.3.6.3.6 Dutch doors shall be permitted where they conform to 19.3.6.3.6 In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel. Reference NFPA 101, 4.6.12.1 Maintenance. Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The corridor doors were non-compliant, specific findings include: The following corridor doors did not close latch and seal tight in there frames:
a) Rooms A-4063, A-4031, A-4031
b) Room A-3083

Reference NFPA 101, 18.3.6.3, 4.6.12.1
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The smoke barrier doors was non-compliant, specific findings include:
1) The cross corridor doors not latching smoke tight. Location: new tower 2nd floor - A2002
2) The cross corridor door did not release with fire alarm activation. Location: new tower 4th floor - A4103
3) The suite doors did not have positive latching. Location: new tower 1st floor, ER beside break room.
4) The cross corridor doors did not close smoke tight. Location: new tower 3rd floor near public elevators.
5) The vision panels in the 1-1/2 hour rated cross corridor doors was not rated. Location: new tower lower level - separating new from old tower.



Reference NFPA 101, 18.3.7.5, 18.3.7.6, 18.3.7.8, 18.3.6.5, 18.3.6.3.1
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The hazardous areas were non-compliant, specific findings include:
1) Doors to rooms did not close/latch/seal properly to maintain required fire resistance rating in the following locations.
a) New tower 4th floor - soiled linen room A-4023
b) New tower lower level - soiled linen room A-0039 in operating room area
c) New tower 1st floor - soiled linen room A-1163
d) New tower 1st floor - storage room A-1157 - orthopedic storage
e) New tower 3rd floor - storage room A-3079
2) Walls and ceilings to rooms were not protected properly to maintain required fire resistance rating in the following locations:
a) New tower 3rd floor - central monitoring room A-3083 (data cable conduit in ceiling)
b) New tower 3rd floor - communications room A-3084 (data cable conduit in ceiling)

Reference NFPA 101, 18.3.5.4, 8.4.1
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The hazardous areas were non-compliant, specific findings include:
1) The hazardous area was not sprinklered nor separated with one hour construction.
Location: old tower 1st floor - oncology record storage
2) The bedroom used for storage did not have a closure installed.
Location: old tower 3rd floor near room 315 & 308
3) The corridor doors between the kitchen and service corridor did not close and latch tight in there frames. Location: old tower lower level near kitchen


Reference NFPA 101, 19.3.5.4, 8.4.1
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The exit access was non-compliant, specific findings include:
1) The staff were not familiar on how to unlock the magnetically locked doors with the master override switch located at the nurse station. Location: New tower 2nd floor - 2A - women's center
2) The magnetic locked doors did not release with activation of the fire alarm system.
a) Using special locking, in activation of fire alarm by smoke heads, the cross corridor doors and the exit stairwell did not release. Doors did release with override switch at door, master override switch and loss of power. The doors were disarmed and security put in place. Location: New tower 2nd floor - 2A - women's center
b) Using delayed egress, in activation of fire alarm, the cross corridor door did not release. Doors did release with delayed egress and loss of power. The doors were disarmed and security put in place. Location: New tower 4th floor - surgical suite
3) Required exit access was not a solid path, easily maintained in inclement weather, to a public way. Location: new tower 1st floor - x-ray stair B exit

Reference NFPA 101, 7.2.1.6 Special locking arrangements, 19.2.1 means of egress
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The exit access was non-compliant, specific findings include: Doors in the following locations required more than one range of motion to exit the area.
1) Old tower 2nd floor Vance Granville community hospital classroom - VGCH - room 2008 & computer room
2) Old tower 2nd floor - breast feeding room
3) Old tower 2nd floor - lactation room
4) Old tower 2nd floor - respiratory break room
5) Old tower 2nd floor - oxygen storage sleep lab
6) Old tower 1st floor - inpatient rehab-rooms R1 through R11
7) Old tower 1st floor - hall entrance to chapel lobby at massage chair
8) Old tower 1st floor - lab

Reference NFPA 101 7.2.1.5.4 Doors shall be operable with not more than one releasing operation. Reference NFPA 101 19.2.1 means of egress
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The egress illumination was non-compliant, specific findings include:
1) Approximately fifty percent of the exit discharge lighting at multiple exits on the old tower was not functioning properly and not providing the required illumination required for exit discharge lighting.
2) The room would leave the staff in darkness. Location: old tower 1st floor morgue cooler.

Reference NFPA 101 7.8.1.1, 7.8.1.3 and 7.8.1.4 Lighting must be arranged to provide light from the exit discharge leading to the public way (parking lot). The walking surfaces within the exit discharge shall be illuminated to values of at least 1 ft-candle measured at the floor. Failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candles in any designated area.
Reference NFPA 101, 19.2.8, 7.8, 7.8.1.2 Illumination of means of egress shall be continuous during the time that the condition of occupancy require the means of egress be available for use.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The egress illumination was non-compliant, specific findings include: Approximately fifty percent of the exit discharge lighting at multiple exits on the new tower was not functioning properly and not providing the required illumination required for exit discharge lighting.


Reference NFPA 101 7.8.1.1, 7.8.1.3 and 7.8.1.4 Lighting must be arranged to provide light from the exit discharge leading to the public way (parking lot). The walking surfaces within the exit discharge shall be illuminated to values of at least 1 ft-candle measured at the floor. Failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candles in any designated area.
Reference NFPA 101, 18.2.8, 7.8, 7.8.1.2 Illumination of means of egress shall be continuous during the time that the condition of occupancy require the means of egress be available for use.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The fire alarm control panel, FACP, and it's system was non-compliant, specific findings include:

1) The FACP was in trouble condition upon arrival. The panel indicated, clean utility Z108 drift tolerance. Location: new tower, 1st floor - security area with the main panel located across from the elevators on the lower level.
2) The FACP did not have audible with loss of battery back up (had visual) Location: new tower, 1st floor - security area with the main panel located across from the elevators on the lower level.
3) The FACP did not have an audible nor visual signal with loss of phone line. Location: new tower, 1st floor - security area with the main panel located across from the elevators on the lower level.
4) Documentation indicated, from Tyco report dated 10/31/14, that the cross corridor doors Electromechanical release devices were 74 in total and 47 passed, 27 failed to release with fire alarm activation. Maintenance stated that the electromechanical release devices to the doors had been repaired however documentation could not be provided. Please confirm.
5) The cross corridor doors between A & B tower did not release upon activation of fire alarm.
6) The cross corridor door located near the public elevator lobby on 4th floor did not release upon activation of fire alarm.

Reference NFPA 101, 9.6.1.4 NFPA 70 and 72
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The automatic sprinkler system was non-compliant, specific findings include: The office located in the receiving storage room was not protected with sprinkler coverage. This office is located in a severe hazardous storage room and is the only space not provided with sprinkler coverage but is one hour rated.

Reference NFPA 101; 8.4.1 special hazard protection
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The automatic sprinkler system was non-compliant, specific findings include: sprinkler head coverage was missing. Location: new tower, 1st floor - the exit vestibule at stairwell B.

NFPA 101 18.3.5, NFPA 13 automatic sprinkler systems
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The automatic sprinkler system was non-compliant, specific findings include: The sprinkler tamper alarms gave a visual signal but not an audible signal when in the closed position at the Fire Alarm remote annunciator located in the Security Office. Location: new tower - riser room

Reference NFPA 72, 9.7.2.1 Distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The automatic sprinkler system was non-compliant, specific findings include: There are two sprinkler valves located in the receiving storage room that are not equipped with electronically supervised tamper alarms.

Reference NFPA 72, 9.7.2.1 Distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The automatic sprinkler system was non-compliant, specific findings include:
1) Documentation from certifications indicated facility was aware of the items that are in need of repair. There is no indication that this item has been corrected. Report from service on 7/21/14 shows:
a) Gauges calibrated or replaced in 2004-2005. Due every five years.
b) Five year obstruction testing is due on all systems.
c) Tamper switch in mechanical room #5 did not report to panel.
d) Outside fire pump room has one piece of 8" pipe by 12" filler piece is corroded and starting to leak. note states: This repair will require shutdown of whole building and also shutting down domestic.
e) Backflows due to be tested November 2012.
2) The sprinkler gauge does not have a date. Location: new tower 4th floor to penthouse - stairwell A 4.5
3) The sprinkler heads were covered in dust and lint and not maintained in good condition Location: new tower 4th floor - Anti-Room A-4051 and other areas throughout the tower.


Reference NFPA 101 section 19.7.6, 4.6.12, NFPA 13, NFPA 25 9.7.5 Required automatic sprinkler systems are continuously maintained in reliable operating condition.
Reference NFPA 101, 19.7.6, 4.6.12, NFPA 13
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The sprinkler system was non-compliant, specific findings include: The sprinkler heads located in the following rooms were covered in dust and lint and not maintained in good condition.
a) old tower 4th floor - rooms B-4061, B-4057
b) old tower 4th floor - breezeway area family waiting room

Reference NFPA 101 19.7.6, 4.6.12, NFPA 13 A sprinkler system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The Heating, Ventilating, and Air Conditioning system (HVAC) was non-compliant, specific findings include:
1) The HVAC emergency shut down switch did not function properly in the following locations:
a) old tower 4th floor nurses station
b) old tower 1st floor inpatient rehab
2) There was dust/dirt on the fire/smoke dampers in the return duct. Could not verify that the device would operate as required. Location: old tower 4th floor breezeway (this continued on all floors)

Reference NFPA 101, 19.5.2.1, 9.2, NFPA 90A, 4-2 Heating, Ventilating and Air Conditioning
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The Heating, Ventilating, and Air Conditioning system (HVAC) was non-compliant, specific findings include: The HVAC units did not shutdown with activation of fire alarm by smoke detector. These units control 1st, 2nd, 3rd and 4th floors. Location: new tower, penthouse.

Reference NFPA 101, 18.5.2.2, 9.2, NFPA 90A, 4-2 Heating, Ventilating and Air Conditioning
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The space heating device was non-compliant, specific findings include: An unapproved electric heater was found in the old tower 3rd floor, dialysis treatment room and in the lowere level house keeping services office.

Reference NFPA 101; 19.7.8 Portable space-Heating devices shall be prohibited in all health care occupancies.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The means of egress was non-compliant, specific findings include:
1) Items stored on the corridor not in immediate use:
a) medical/computer cart(s) Location: old tower 4th floor - Between rooms 443/444
b) empty bed Location: old tower 4th floor - breezeway to new tower
2) Corridor door opens into means of egress not 180 degrees when open leaving an 18" projection into the corridor. Location: old tower 2nd floor - old laundry chute closet.
3) Shelving unit doors block egress when open leaving an 18" projection into the corridor. Doors did not have self closing hinges. Location: Old tower 4th floor-medical unit breezeway
4) Wall mounted retractable medical charts extend down without a retractable hinge impending in the means of egress leaving an 18" projection into the corridor. Location: old Tower entire 4th floor
5) There were Blood Pressure (BP) machines that were found plugged in and charging in the corridor throughout the floor, not in sight of the nurses station. Location: Old tower - 4th floor



Reference NFPA 101, 7.1.10 - storage in hall
Reference NFPA 101 19.2.1 means of egress
Reference NFPA 101, 19.7.6, 4.6.12, NFPA 13
NFPA 7.2.1.4.4 states during its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The means of egress was non-compliant, specific findings include:
1) Items stored on the corridor not in immediate use:
a) Operating Room, OR, back hall
b) Emergency Department, ED, corridor
2) There were Blood Pressure (BP) machines that were found plugged in and charging in the corridor throughout the floor, not in sight of the nurses station. Location: New tower - 4th - across from room 25 and 16
3) Corridor door opens into means of egress, not 180 degrees, when open leaving an 18" projection into the corridor. Location as follows:
a) new tower 4th floor - electrical closet
b) new tower 1st floor - electrical closet between X-Ray and ED
c) new tower 1st floor - x-ray across from nuclear medicine A1106 & A1104


Reference NFPA 101, 7.1.10 - storage in hall
Reference NFPA 101, 18.7.6, 4.6.12, NFPA 13
NFPA 7.2.1.4.4 states during its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The medical gas storage was non-compliant, specific findings include: Full and empty oxygen cylinders were stored together. Location: new tower 4th floor - nurses station

Reference: NFPA 99 4.3.1.1.2, 18.3.2.4
Reference: NFPA 99 4-3.5.2.2 b(2) If stored within the same enclosure, empty cylinders shall be segregated and designated (with signage) from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1:00 PM onward, the following deficiencies were noted: The oxygen storage was non-compliant, specific findings include:
1) The outside bulk oxygen storage was not protected from inclement weather. Location: old tower near emergency generators.
2) The outside bulk oxygen storage was sitting directly on the concrete floor without protection beneath to prevent rusting. Location: old tower near emergency generators.
3) The outside bulk oxygen storage was gang chained together . Location: old tower near emergency generators.


Reference NFPA 99, 4-3.5.2.2 Cylinders stored in the open shall be protected against extremes of weather and from the ground beneath to prevent rusting.
Reference NFPA 99, 4-3..1.1.2 a (3) Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
Reference NFPA 99 4-5..1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: Documentation indicated the anesthetizing locations were non-compliant, specific findings include: The relative humidity in all five working operating rooms was less than 35%. The typical reading was 20% on several occaisons.

Reference NFPA 99 4.3.1.2.3(n) and 5.4.1.1, 18.3.2.3
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The smoke dampers were non-compliant, specific findings include: The smoke dampers located in the smoke walls did not close upon activation of fire alarm with smoke detector. Location: new tower 4th floor

NFPA 101; 8.3.6, NFPA 90A
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The emergency generator components were non-compliant, specific findings include:
1) Three (3) generator annunciator panels did not function when tested. There was not an audible nor visual indicator when tested. Location: new tower 1st floor -security
2) Low fuel alarm was not provide for and/or tested for the emergency generators.
3) The fire pump remote annunciator panel did not provide a visual and audible signal when power was transferred from normal to emergency power.

Reference NFPA 99 3-4.1.1.15, NFPA 70, National Electrical Code, Section 700-12 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. 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}
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The generator annunciator panel was non-compliant, specific findings include: The generator annunciator panel was not in an area likely to be heard. Location: old tower 1st floor - old lobby- John T Church building

Reference NFPA 99 3-4.1.1.15, NFPA 70, National Electrical Code, Section 700-12 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. This deficiency affected one of four generators.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The electrical wiring was non-compliant, specific findings include: Non-permanent wiring was found in the following locations:
a) Old tower 4th floor - alcove at stairwell C & D
b) Old tower lower level - Overhead pigtail lighting in Lab Shell space

Reference NFPA 70, National Electrical Code 9.1.2 Permanent wiring
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The building construction type was non-compliant, specific findings include: There are penetrations in the corridor wall (two) new tower 1st floor ed/x-ray entrance hall in order to maintain the required rating of the wall.

Reference NFPA 101, 18.1.6.2, 18.1.6.3, 18.2.5.1
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The building construction type was non-compliant, specific findings include: The one hour corridor wall to the Lab Shell space located at the double door and HR is not sealed conduit penetrations at the top of the wall in order to maintain the required fire resistance rating of the wall. Location: Old Tower lower level, near HR

Reference NFPA 101, 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.70(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The corridor doors were non-compliant, specific findings include:
1) Roller latches were used in the following areas:
a) Old tower 2nd floor - Vance Granville Community Hospital classroom, VGCH, room 2008 and adjacent computer room.
b) Old tower 3rd floor near room 344
2) There was a Dutch door that the upper leaf was not equipped with a latching device nor a astragal, rabbet or bevel. Location: old tower 1st floor - infection control


Reference NFPA 101, 19.3.6.3.1 Roller latches are prohibited by CMS regulations in all health care facilities. Reference NFPA 101 19.3.6.3.6 Dutch doors shall be permitted where they conform to 19.3.6.3.6 In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel. Reference NFPA 101, 4.6.12.1 Maintenance. Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The corridor doors were non-compliant, specific findings include: The following corridor doors did not close latch and seal tight in there frames:
a) Rooms A-4063, A-4031, A-4031
b) Room A-3083

Reference NFPA 101, 18.3.6.3, 4.6.12.1
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The smoke barrier doors was non-compliant, specific findings include:
1) The cross corridor doors not latching smoke tight. Location: new tower 2nd floor - A2002
2) The cross corridor door did not release with fire alarm activation. Location: new tower 4th floor - A4103
3) The suite doors did not have positive latching. Location: new tower 1st floor, ER beside break room.
4) The cross corridor doors did not close smoke tight. Location: new tower 3rd floor near public elevators.
5) The vision panels in the 1-1/2 hour rated cross corridor doors was not rated. Location: new tower lower level - separating new from old tower.



Reference NFPA 101, 18.3.7.5, 18.3.7.6, 18.3.7.8, 18.3.6.5, 18.3.6.3.1
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The hazardous areas were non-compliant, specific findings include:
1) Doors to rooms did not close/latch/seal properly to maintain required fire resistance rating in the following locations.
a) New tower 4th floor - soiled linen room A-4023
b) New tower lower level - soiled linen room A-0039 in operating room area
c) New tower 1st floor - soiled linen room A-1163
d) New tower 1st floor - storage room A-1157 - orthopedic storage
e) New tower 3rd floor - storage room A-3079
2) Walls and ceilings to rooms were not protected properly to maintain required fire resistance rating in the following locations:
a) New tower 3rd floor - central monitoring room A-3083 (data cable conduit in ceiling)
b) New tower 3rd floor - communications room A-3084 (data cable conduit in ceiling)

Reference NFPA 101, 18.3.5.4, 8.4.1
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The hazardous areas were non-compliant, specific findings include:
1) The hazardous area was not sprinklered nor separated with one hour construction.
Location: old tower 1st floor - oncology record storage
2) The bedroom used for storage did not have a closure installed.
Location: old tower 3rd floor near room 315 & 308
3) The corridor doors between the kitchen and service corridor did not close and latch tight in there frames. Location: old tower lower level near kitchen


Reference NFPA 101, 19.3.5.4, 8.4.1
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The exit access was non-compliant, specific findings include:
1) The staff were not familiar on how to unlock the magnetically locked doors with the master override switch located at the nurse station. Location: New tower 2nd floor - 2A - women's center
2) The magnetic locked doors did not release with activation of the fire alarm system.
a) Using special locking, in activation of fire alarm by smoke heads, the cross corridor doors and the exit stairwell did not release. Doors did release with override switch at door, master override switch and loss of power. The doors were disarmed and security put in place. Location: New tower 2nd floor - 2A - women's center
b) Using delayed egress, in activation of fire alarm, the cross corridor door did not release. Doors did release with delayed egress and loss of power. The doors were disarmed and security put in place. Location: New tower 4th floor - surgical suite
3) Required exit access was not a solid path, easily maintained in inclement weather, to a public way. Location: new tower 1st floor - x-ray stair B exit

Reference NFPA 101, 7.2.1.6 Special locking arrangements, 19.2.1 means of egress
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The exit access was non-compliant, specific findings include: Doors in the following locations required more than one range of motion to exit the area.
1) Old tower 2nd floor Vance Granville community hospital classroom - VGCH - room 2008 & computer room
2) Old tower 2nd floor - breast feeding room
3) Old tower 2nd floor - lactation room
4) Old tower 2nd floor - respiratory break room
5) Old tower 2nd floor - oxygen storage sleep lab
6) Old tower 1st floor - inpatient rehab-rooms R1 through R11
7) Old tower 1st floor - hall entrance to chapel lobby at massage chair
8) Old tower 1st floor - lab

Reference NFPA 101 7.2.1.5.4 Doors shall be operable with not more than one releasing operation. Reference NFPA 101 19.2.1 means of egress
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The egress illumination was non-compliant, specific findings include:
1) Approximately fifty percent of the exit discharge lighting at multiple exits on the old tower was not functioning properly and not providing the required illumination required for exit discharge lighting.
2) The room would leave the staff in darkness. Location: old tower 1st floor morgue cooler.

Reference NFPA 101 7.8.1.1, 7.8.1.3 and 7.8.1.4 Lighting must be arranged to provide light from the exit discharge leading to the public way (parking lot). The walking surfaces within the exit discharge shall be illuminated to values of at least 1 ft-candle measured at the floor. Failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candles in any designated area.
Reference NFPA 101, 19.2.8, 7.8, 7.8.1.2 Illumination of means of egress shall be continuous during the time that the condition of occupancy require the means of egress be available for use.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The egress illumination was non-compliant, specific findings include: Approximately fifty percent of the exit discharge lighting at multiple exits on the new tower was not functioning properly and not providing the required illumination required for exit discharge lighting.


Reference NFPA 101 7.8.1.1, 7.8.1.3 and 7.8.1.4 Lighting must be arranged to provide light from the exit discharge leading to the public way (parking lot). The walking surfaces within the exit discharge shall be illuminated to values of at least 1 ft-candle measured at the floor. Failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candles in any designated area.
Reference NFPA 101, 18.2.8, 7.8, 7.8.1.2 Illumination of means of egress shall be continuous during the time that the condition of occupancy require the means of egress be available for use.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The fire alarm control panel, FACP, and it's system was non-compliant, specific findings include:

1) The FACP was in trouble condition upon arrival. The panel indicated, clean utility Z108 drift tolerance. Location: new tower, 1st floor - security area with the main panel located across from the elevators on the lower level.
2) The FACP did not have audible with loss of battery back up (had visual) Location: new tower, 1st floor - security area with the main panel located across from the elevators on the lower level.
3) The FACP did not have an audible nor visual signal with loss of phone line. Location: new tower, 1st floor - security area with the main panel located across from the elevators on the lower level.
4) Documentation indicated, from Tyco report dated 10/31/14, that the cross corridor doors Electromechanical release devices were 74 in total and 47 passed, 27 failed to release with fire alarm activation. Maintenance stated that the electromechanical release devices to the doors had been repaired however documentation could not be provided. Please confirm.
5) The cross corridor doors between A & B tower did not release upon activation of fire alarm.
6) The cross corridor door located near the public elevator lobby on 4th floor did not release upon activation of fire alarm.

Reference NFPA 101, 9.6.1.4 NFPA 70 and 72
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The automatic sprinkler system was non-compliant, specific findings include: The office located in the receiving storage room was not protected with sprinkler coverage. This office is located in a severe hazardous storage room and is the only space not provided with sprinkler coverage but is one hour rated.

Reference NFPA 101; 8.4.1 special hazard protection
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The automatic sprinkler system was non-compliant, specific findings include: sprinkler head coverage was missing. Location: new tower, 1st floor - the exit vestibule at stairwell B.

NFPA 101 18.3.5, NFPA 13 automatic sprinkler systems
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The automatic sprinkler system was non-compliant, specific findings include: The sprinkler tamper alarms gave a visual signal but not an audible signal when in the closed position at the Fire Alarm remote annunciator located in the Security Office. Location: new tower - riser room

Reference NFPA 72, 9.7.2.1 Distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The automatic sprinkler system was non-compliant, specific findings include: There are two sprinkler valves located in the receiving storage room that are not equipped with electronically supervised tamper alarms.

Reference NFPA 72, 9.7.2.1 Distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The automatic sprinkler system was non-compliant, specific findings include:
1) Documentation from certifications indicated facility was aware of the items that are in need of repair. There is no indication that this item has been corrected. Report from service on 7/21/14 shows:
a) Gauges calibrated or replaced in 2004-2005. Due every five years.
b) Five year obstruction testing is due on all systems.
c) Tamper switch in mechanical room #5 did not report to panel.
d) Outside fire pump room has one piece of 8" pipe by 12" filler piece is corroded and starting to leak. note states: This repair will require shutdown of whole building and also shutting down domestic.
e) Backflows due to be tested November 2012.
2) The sprinkler gauge does not have a date. Location: new tower 4th floor to penthouse - stairwell A 4.5
3) The sprinkler heads were covered in dust and lint and not maintained in good condition Location: new tower 4th floor - Anti-Room A-4051 and other areas throughout the tower.


Reference NFPA 101 section 19.7.6, 4.6.12, NFPA 13, NFPA 25 9.7.5 Required automatic sprinkler systems are continuously maintained in reliable operating condition.
Reference NFPA 101, 19.7.6, 4.6.12, NFPA 13
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The sprinkler system was non-compliant, specific findings include: The sprinkler heads located in the following rooms were covered in dust and lint and not maintained in good condition.
a) old tower 4th floor - rooms B-4061, B-4057
b) old tower 4th floor - breezeway area family waiting room

Reference NFPA 101 19.7.6, 4.6.12, NFPA 13 A sprinkler system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The Heating, Ventilating, and Air Conditioning system (HVAC) was non-compliant, specific findings include:
1) The HVAC emergency shut down switch did not function properly in the following locations:
a) old tower 4th floor nurses station
b) old tower 1st floor inpatient rehab
2) There was dust/dirt on the fire/smoke dampers in the return duct. Could not verify that the device would operate as required. Location: old tower 4th floor breezeway (this continued on all floors)

Reference NFPA 101, 19.5.2.1, 9.2, NFPA 90A, 4-2 Heating, Ventilating and Air Conditioning
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The Heating, Ventilating, and Air Conditioning system (HVAC) was non-compliant, specific findings include: The HVAC units did not shutdown with activation of fire alarm by smoke detector. These units control 1st, 2nd, 3rd and 4th floors. Location: new tower, penthouse.

Reference NFPA 101, 18.5.2.2, 9.2, NFPA 90A, 4-2 Heating, Ventilating and Air Conditioning
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The space heating device was non-compliant, specific findings include: An unapproved electric heater was found in the old tower 3rd floor, dialysis treatment room and in the lowere level house keeping services office.

Reference NFPA 101; 19.7.8 Portable space-Heating devices shall be prohibited in all health care occupancies.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The means of egress was non-compliant, specific findings include:
1) Items stored on the corridor not in immediate use:
a) medical/computer cart(s) Location: old tower 4th floor - Between rooms 443/444
b) empty bed Location: old tower 4th floor - breezeway to new tower
2) Corridor door opens into means of egress not 180 degrees when open leaving an 18" projection into the corridor. Location: old tower 2nd floor - old laundry chute closet.
3) Shelving unit doors block egress when open leaving an 18" projection into the corridor. Doors did not have self closing hinges. Location: Old tower 4th floor-medical unit breezeway
4) Wall mounted retractable medical charts extend down without a retractable hinge impending in the means of egress leaving an 18" projection into the corridor. Location: old Tower entire 4th floor
5) There were Blood Pressure (BP) machines that were found plugged in and charging in the corridor throughout the floor, not in sight of the nurses station. Location: Old tower - 4th floor



Reference NFPA 101, 7.1.10 - storage in hall
Reference NFPA 101 19.2.1 means of egress
Reference NFPA 101, 19.7.6, 4.6.12, NFPA 13
NFPA 7.2.1.4.4 states during its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The means of egress was non-compliant, specific findings include:
1) Items stored on the corridor not in immediate use:
a) Operating Room, OR, back hall
b) Emergency Department, ED, corridor
2) There were Blood Pressure (BP) machines that were found plugged in and charging in the corridor throughout the floor, not in sight of the nurses station. Location: New tower - 4th - across from room 25 and 16
3) Corridor door opens into means of egress, not 180 degrees, when open leaving an 18" projection into the corridor. Location as follows:
a) new tower 4th floor - electrical closet
b) new tower 1st floor - electrical closet between X-Ray and ED
c) new tower 1st floor - x-ray across from nuclear medicine A1106 & A1104


Reference NFPA 101, 7.1.10 - storage in hall
Reference NFPA 101, 18.7.6, 4.6.12, NFPA 13
NFPA 7.2.1.4.4 states during its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The medical gas storage was non-compliant, specific findings include: Full and empty oxygen cylinders were stored together. Location: new tower 4th floor - nurses station

Reference: NFPA 99 4.3.1.1.2, 18.3.2.4
Reference: NFPA 99 4-3.5.2.2 b(2) If stored within the same enclosure, empty cylinders shall be segregated and designated (with signage) from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1:00 PM onward, the following deficiencies were noted: The oxygen storage was non-compliant, specific findings include:
1) The outside bulk oxygen storage was not protected from inclement weather. Location: old tower near emergency generators.
2) The outside bulk oxygen storage was sitting directly on the concrete floor without protection beneath to prevent rusting. Location: old tower near emergency generators.
3) The outside bulk oxygen storage was gang chained together . Location: old tower near emergency generators.


Reference NFPA 99, 4-3.5.2.2 Cylinders stored in the open shall be protected against extremes of weather and from the ground beneath to prevent rusting.
Reference NFPA 99, 4-3..1.1.2 a (3) Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
Reference NFPA 99 4-5..1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: Documentation indicated the anesthetizing locations were non-compliant, specific findings include: The relative humidity in all five working operating rooms was less than 35%. The typical reading was 20% on several occaisons.

Reference NFPA 99 4.3.1.2.3(n) and 5.4.1.1, 18.3.2.3
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The smoke dampers were non-compliant, specific findings include: The smoke dampers located in the smoke walls did not close upon activation of fire alarm with smoke detector. Location: new tower 4th floor

NFPA 101; 8.3.6, NFPA 90A
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The emergency generator components were non-compliant, specific findings include:
1) Three (3) generator annunciator panels did not function when tested. There was not an audible nor visual indicator when tested. Location: new tower 1st floor -security
2) Low fuel alarm was not provide for and/or tested for the emergency generators.
3) The fire pump remote annunciator panel did not provide a visual and audible signal when power was transferred from normal to emergency power.

Reference NFPA 99 3-4.1.1.15, NFPA 70, National Electrical Code, Section 700-12 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. 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}
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The generator annunciator panel was non-compliant, specific findings include: The generator annunciator panel was not in an area likely to be heard. Location: old tower 1st floor - old lobby- John T Church building

Reference NFPA 99 3-4.1.1.15, NFPA 70, National Electrical Code, Section 700-12 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. This deficiency affected one of four generators.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

42 CFR 482.41(a)

Based on observations, on 3/2/2015 at approximately 1 PM onward, the following deficiencies were noted: The electrical wiring was non-compliant, specific findings include: Non-permanent wiring was found in the following locations:
a) Old tower 4th floor - alcove at stairwell C & D
b) Old tower lower level - Overhead pigtail lighting in Lab Shell space

Reference NFPA 70, National Electrical Code 9.1.2 Permanent wiring
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke