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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.



Based on observations, on 5/5/2015 at approximately 9 AM onward, the following deficiencies remained outstanding from the above:
Item 1) a and b

Item 2 has been corrected.

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.


Based on observations, on 5/5/2015 at approximately 9 AM onward, the following deficiencies remained outstanding from the above:
Items 3 and 5

Items 1, 2 and 4 have been corrected

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


Based on observations, on 5/5/2015 at approximately 9 AM onward, the following deficiencies remained outstanding from the above:
Items 1) a, b and d

Items 1) c and e and 2) a and b have been corrected.

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.


Based on observations, on 5/5/2015 at approximately 9 AM onward, the following deficiencies remained outstanding from the above:
Item 3

Items 1 & 2 have been corrected

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.


Based on observations, on 5/5/2015 at approximately 9 AM onward, the following deficiencies remained outstanding from the above:
Item 1, 2, 3, 4, 5, 7

Items 6 & 8 have been corrected

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


Based on observations, on 5/5/2015 at approximately 9 AM onward, the following deficiencies remained outstanding from the above:
Item 1, 2 and 3

Items 4, 5 and 6 have been corrected

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

Based on observations, on 5/5/2015 at approximately 9 AM onward, the above deficiency remained outstanding.

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.


Based on observations, on 5/5/2015 at approximately 9 AM onward, the above deficiency remained outstanding.

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.


Based on observations, on 5/5/2015 at approximately 9 AM onward, the above deficiency remained outstanding.

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


Based on observations, on 5/5/2015 at approximately 9 AM onward, the following deficiencies remained outstanding from the above:
Item 1) b

Items 1) a and item 2 have been corrected.

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


Based on observations, on 5/5/2015 at approximately 9 AM onward, the following deficiencies remained outstanding from the above:
Item 3

Items 1, 2, 4 and 5 have been corrected

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


Based on observations, on 5/5/2015 at approximately 9 AM onward, the following deficiencies remained outstanding from the above:
Items 1) a and b and item 3) a

Items 2 and 3) b and c have been corrected.

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


Based on observations, on 5/5/2015 at approximately 9 AM onward, the above deficiency remained outstanding.