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Building A-1 - Main Hospital

Through observation during the survey,April 17 and 8, 2013, it was determined that the facility failed to maintain the two hour fire resistance rating of the common wall between the Hospital and the Assembly occupancy (Dining Room).

During the walk through of the facility, with the Maintenance Director, the 1-1/2-hour, fire-rated doors contained a gap larger than 1/8" when closed.
Per 19.1.2.2 and 1999 edition of NFPA 80, (Chapter 2, Paragraph 2-1.4). This set of double doors is an intricate part of the two-hour fire-rated separation between the occupancies.

This deficiency effected 1 of 3 smoke compartments

Building A-1 - Main Hospital

It was determined by observation during the survey, April 17 and 18, 2013, that the corridor doors did not positively latch into the frames

One (1) 70/30 double door was not considered to be positive latching, on the "30 side", when in the closed position. The door to X-ray #1 contained slide locks on the "30 side" of the door for locking, which is not considered to be a positive latching device. This door enters into a corridor and must be a positive latching door.
Per NFPA 101, Chapter 18, section 18.3.6.3.6

This deficiency effected 1 of 3 smoke compartments

Building A-1 - Main Hospital

Through observation during the survey, April 17 and 18, 2013, it was determined that the facility failed to maintain the smoke barrier doors.

During the walk through of the facility, with the Maintenance Director, three (3) smoke barrier doors contained gaps between the leading edges of the doors.
1) #2161-1
2) #1109
3) #2141
Per NFPA 101, Chapter 18, section 8.3.7.8

This deficiency effected 3 of 3 smoke compartments

Building AB - Therapy at the Mall

Through observation during the survey, April 17 and 18, 2013, it was determined the facility failed to maintain all exit doors.

During the walk-through of the facility, with the Maintenance Director;
1) The front door did not contain the correct signage as required. The principle entrance/exit must contain a sign that states that the door must be unlocked at all times.
2) The front door lock was not distinguishable as being locked when in the locked position
3) The back exit door contained a thumb lock deadbolt and a lock on the turn handle knob of the door. This door can only cantain one (1) locking mechanism on the door and cannot require two actions unlock and open the door.

Per 39.2.2.2.2 and 7.2.1.5.1
"Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
Exception No. 1: This requirement shall not apply where otherwise provided in Chapters 18 through 23.
Exception No. 2: Exterior doors shall be permitted to have key-operated locks from the egress side, provided that the following criteria are met:
(a) Permission to use this exception is provided in Chapters 12 through 42 for the specific occupancy.
(b) On or adjacent to the door, there is a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high on a contrasting background that reads as follows:
THIS DOOR TO REMAIN UNLOCKED
WHEN THE BUILDING IS OCCUPIED
(c) The locking device is of a type that is readily distinguishable as locked.
(d) A key is immediately available to any occupant inside the building when it is locked."

This deficiency effected 1 of 1smoke compartment, 2 staff members and all patients

Building A-1 - Main Hospital

Through observation testing during the survey, April 17 and 18, 2013, it was determined that the facility failed to maintain the exits as readily accessible at all times.

During the walk through of the facility, with the Maintenance Director:
1) One (1) egress door, located outside of the OB Suite #3178-1, contained a delayed egress magnetic hold system that would not release unless the door contained pressure for the full fifteen (15) seconds. The door must start the irreversible process once the door is pushed for no more than three (3) seconds.
2) The delayed egress alarm on the exit door at the OB/GYN exit contains a pre-alarm, in which the door would sound an alarm during the first three (3) seconds of pushing the delayed egress bar.
Per NFPA 101, section 7.2.1.6.1(C)

This deficiency effected 10 residents in 1 smoke compartment

Building AA - MOB

Through observation during the survey, April 17 and 18, 2013, it was determined the facility failed to maintain all exit access as required.

During the walk-through of the facility, with the Maintenance Director, the facility maintained a dead end corridor that was longer than twenty feet (20'). This corridor located at the "4 South" wing contained a lock on the double door. This locked door created a dead end corridor of approximately fifty feet (50') long.
Per NFPA 101, Chapter 38, section 38.2.5.2. "Dead end corridors shall not exceed 20 ft."

This deficiency effected 1 of 3 smoke compartments and 6 staff members

Building A-1 - Main Hospital

Through record review and discussions during the survey, August 17 and 18, 2013, it was determined that the facility failed to conduct fire drills at on each shift quarterly.

During the review of the facility records, with the Maintenance Director, the facility failed to document a fire drill during the first (1st) quarter on the second (2nd) shift.

This deficiency effected all patients and staff

Building A-1 - Main Hospital

Through a review of the records and discussions during the survey, April 17 and 18, 2013, it was determined that the facility failed to inspect and test the fire alarm per NFPA 72.

During the review of the facility records, with the Maintenance Director, documentation was not available to verify the fire alarm system sensitivity test occured within the past year.
Per NFPA 101 2000 Edition 18.3.4.5.1, 9.6.1, and NFPA 72 7-3 and 7-3.2.1.

This deficiency effected 3 of 3 smoke compartments

Building AA - MOB

Through a review of the records and discussions during the survey, April 17 and 18, 2013, it was determined that the facility failed to inspect and test the fire alarm system.

During the review of the facility records, with the Maintenance Director, documentation was not available to verify the sensitivity testing of the smoke detectors was conducted in the past two (2) years.

This deficiency effected 4 of 4 smoke compartments

Building A-1 - Main Hospital

Through observation and record review during the survey, April 17 and 18, 2013, it was determined the facility failed to inspect, test and maintain the automatic sprinkler system per NFPA 25.

During the walk through of the facility, with the Maintenance Director, documentation was not available to indicate the quarterly testing of the sprinkler supervisory switches and flow alarms.
Per 1999 Edition of NFPA 25, Chapter 2, section 2-3.3.

This deficiency effected 3 of 3 smoke compartments

Building AA - MOB

Through observation during the survey, April 17 and 18, 2013, it was determined the facility failed to test and maintain the automatic sprinkler system per NFPA 13 and NFPA 25.

During document review and a walk through of the facility, with the Maintenance Director;
1) Documentation was not available to indicate the quarterly test of the wet sprinkler system has occurred in the calendar year of 2012.
Per 1999 Edition of NFPA 25, section 2-1, table 2-1.
2) Documentation was not available to verify that one (1) sprinkler gauge was calibrated or replaced every five (5) years per NFPA 25. The gauge did not contain a manufacturer date.
Per 1999 Edition of NFPA 25, section 2-3.2.
3) Two (2) sprinklers, located in Pediatric treatment rooms #2 and 3) were upright sprinkler heads installed in a pendant position.
Per NFPA 13, section 5-6.

This deficiency effected 4 of 4 smoke compartments

Building A-1 - Main Hospital

Through observation during the survey, April 17 and 18, 2013, it was determined that the facility failed to maintain the egress corridors free of all obstructions or impediments to full instant use in the case of fire or other emergency.

During the walk through of the facility, with the Maintenance Director, one (1) sitting couch was located stored within the corridor egress path outside of the outpatient registration area. The couch protruded approximately twenty four inches (24") into the eight foot (8') corridor.

This deficiency effected 1 of 3 smoke compartments

Building A-1 - Main Hospital

Through observation and record review during the survey, April 17 and 18, 2013, 2010, it was determined that the facility failed to provide curtains that comply with NFPA 701 in all areas.

During record review and walk through of the facility, with the Maintenance Director, curtains and decorations located throughout the facility did not contain tags or markings showing that they met NFPA 701 requirements.
1) Large quilt hanging on the wall in the Chapel
2) Large quilt located in the mammography wing
3) Large quilt located in room 4169-1

This deficiency effected 3 of 3 smoke compartments

Building AA - MOB

Through observation and document review during the survey, April 17 and 18, 2013, it was determined that the facility failed to test the emergency generator per NFPA 110.

During record review, with the Maintenance Director, documentation indicated a monthly test of the generator under a load. All emergency egress lighting located within the facility is located on the emergency generator.
Per 1999 Edition of NFPA 101 section 21.2.9.2 and 7.9.2.3, and 1999 Edition of NFPA 110 6-4.2 and 6-4.2.2. 2 " Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. "
And section 6.4.2.2 " Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours."

This deficiency effected 4 of 4 smoke compartments

Building A-1 - Main Hospital

Through observation during the survey,April 17 and 8, 2013, it was determined that the facility failed to maintain the two hour fire resistance rating of the common wall between the Hospital and the Assembly occupancy (Dining Room).

During the walk through of the facility, with the Maintenance Director, the 1-1/2-hour, fire-rated doors contained a gap larger than 1/8" when closed.
Per 19.1.2.2 and 1999 edition of NFPA 80, (Chapter 2, Paragraph 2-1.4). This set of double doors is an intricate part of the two-hour fire-rated separation between the occupancies.

This deficiency effected 1 of 3 smoke compartments

Building A-1 - Main Hospital

It was determined by observation during the survey, April 17 and 18, 2013, that the corridor doors did not positively latch into the frames

One (1) 70/30 double door was not considered to be positive latching, on the "30 side", when in the closed position. The door to X-ray #1 contained slide locks on the "30 side" of the door for locking, which is not considered to be a positive latching device. This door enters into a corridor and must be a positive latching door.
Per NFPA 101, Chapter 18, section 18.3.6.3.6

This deficiency effected 1 of 3 smoke compartments

Building A-1 - Main Hospital

Through observation during the survey, April 17 and 18, 2013, it was determined that the facility failed to maintain the smoke barrier doors.

During the walk through of the facility, with the Maintenance Director, three (3) smoke barrier doors contained gaps between the leading edges of the doors.
1) #2161-1
2) #1109
3) #2141
Per NFPA 101, Chapter 18, section 8.3.7.8

This deficiency effected 3 of 3 smoke compartments

Building AB - Therapy at the Mall

Through observation during the survey, April 17 and 18, 2013, it was determined the facility failed to maintain all exit doors.

During the walk-through of the facility, with the Maintenance Director;
1) The front door did not contain the correct signage as required. The principle entrance/exit must contain a sign that states that the door must be unlocked at all times.
2) The front door lock was not distinguishable as being locked when in the locked position
3) The back exit door contained a thumb lock deadbolt and a lock on the turn handle knob of the door. This door can only cantain one (1) locking mechanism on the door and cannot require two actions unlock and open the door.

Per 39.2.2.2.2 and 7.2.1.5.1
"Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
Exception No. 1: This requirement shall not apply where otherwise provided in Chapters 18 through 23.
Exception No. 2: Exterior doors shall be permitted to have key-operated locks from the egress side, provided that the following criteria are met:
(a) Permission to use this exception is provided in Chapters 12 through 42 for the specific occupancy.
(b) On or adjacent to the door, there is a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high on a contrasting background that reads as follows:
THIS DOOR TO REMAIN UNLOCKED
WHEN THE BUILDING IS OCCUPIED
(c) The locking device is of a type that is readily distinguishable as locked.
(d) A key is immediately available to any occupant inside the building when it is locked."

This deficiency effected 1 of 1smoke compartment, 2 staff members and all patients

Building A-1 - Main Hospital

Through observation testing during the survey, April 17 and 18, 2013, it was determined that the facility failed to maintain the exits as readily accessible at all times.

During the walk through of the facility, with the Maintenance Director:
1) One (1) egress door, located outside of the OB Suite #3178-1, contained a delayed egress magnetic hold system that would not release unless the door contained pressure for the full fifteen (15) seconds. The door must start the irreversible process once the door is pushed for no more than three (3) seconds.
2) The delayed egress alarm on the exit door at the OB/GYN exit contains a pre-alarm, in which the door would sound an alarm during the first three (3) seconds of pushing the delayed egress bar.
Per NFPA 101, section 7.2.1.6.1(C)

This deficiency effected 10 residents in 1 smoke compartment

Building AA - MOB

Through observation during the survey, April 17 and 18, 2013, it was determined the facility failed to maintain all exit access as required.

During the walk-through of the facility, with the Maintenance Director, the facility maintained a dead end corridor that was longer than twenty feet (20'). This corridor located at the "4 South" wing contained a lock on the double door. This locked door created a dead end corridor of approximately fifty feet (50') long.
Per NFPA 101, Chapter 38, section 38.2.5.2. "Dead end corridors shall not exceed 20 ft."

This deficiency effected 1 of 3 smoke compartments and 6 staff members

Building A-1 - Main Hospital

Through record review and discussions during the survey, August 17 and 18, 2013, it was determined that the facility failed to conduct fire drills at on each shift quarterly.

During the review of the facility records, with the Maintenance Director, the facility failed to document a fire drill during the first (1st) quarter on the second (2nd) shift.

This deficiency effected all patients and staff

Building A-1 - Main Hospital

Through a review of the records and discussions during the survey, April 17 and 18, 2013, it was determined that the facility failed to inspect and test the fire alarm per NFPA 72.

During the review of the facility records, with the Maintenance Director, documentation was not available to verify the fire alarm system sensitivity test occured within the past year.
Per NFPA 101 2000 Edition 18.3.4.5.1, 9.6.1, and NFPA 72 7-3 and 7-3.2.1.

This deficiency effected 3 of 3 smoke compartments

Building AA - MOB

Through a review of the records and discussions during the survey, April 17 and 18, 2013, it was determined that the facility failed to inspect and test the fire alarm system.

During the review of the facility records, with the Maintenance Director, documentation was not available to verify the sensitivity testing of the smoke detectors was conducted in the past two (2) years.

This deficiency effected 4 of 4 smoke compartments

Building A-1 - Main Hospital

Through observation and record review during the survey, April 17 and 18, 2013, it was determined the facility failed to inspect, test and maintain the automatic sprinkler system per NFPA 25.

During the walk through of the facility, with the Maintenance Director, documentation was not available to indicate the quarterly testing of the sprinkler supervisory switches and flow alarms.
Per 1999 Edition of NFPA 25, Chapter 2, section 2-3.3.

This deficiency effected 3 of 3 smoke compartments

Building AA - MOB

Through observation during the survey, April 17 and 18, 2013, it was determined the facility failed to test and maintain the automatic sprinkler system per NFPA 13 and NFPA 25.

During document review and a walk through of the facility, with the Maintenance Director;
1) Documentation was not available to indicate the quarterly test of the wet sprinkler system has occurred in the calendar year of 2012.
Per 1999 Edition of NFPA 25, section 2-1, table 2-1.
2) Documentation was not available to verify that one (1) sprinkler gauge was calibrated or replaced every five (5) years per NFPA 25. The gauge did not contain a manufacturer date.
Per 1999 Edition of NFPA 25, section 2-3.2.
3) Two (2) sprinklers, located in Pediatric treatment rooms #2 and 3) were upright sprinkler heads installed in a pendant position.
Per NFPA 13, section 5-6.

This deficiency effected 4 of 4 smoke compartments

Building A-1 - Main Hospital

Through observation during the survey, April 17 and 18, 2013, it was determined that the facility failed to maintain the egress corridors free of all obstructions or impediments to full instant use in the case of fire or other emergency.

During the walk through of the facility, with the Maintenance Director, one (1) sitting couch was located stored within the corridor egress path outside of the outpatient registration area. The couch protruded approximately twenty four inches (24") into the eight foot (8') corridor.

This deficiency effected 1 of 3 smoke compartments

Building A-1 - Main Hospital

Through observation and record review during the survey, April 17 and 18, 2013, 2010, it was determined that the facility failed to provide curtains that comply with NFPA 701 in all areas.

During record review and walk through of the facility, with the Maintenance Director, curtains and decorations located throughout the facility did not contain tags or markings showing that they met NFPA 701 requirements.
1) Large quilt hanging on the wall in the Chapel
2) Large quilt located in the mammography wing
3) Large quilt located in room 4169-1

This deficiency effected 3 of 3 smoke compartments

Building AA - MOB

Through observation and document review during the survey, April 17 and 18, 2013, it was determined that the facility failed to test the emergency generator per NFPA 110.

During record review, with the Maintenance Director, documentation indicated a monthly test of the generator under a load. All emergency egress lighting located within the facility is located on the emergency generator.
Per 1999 Edition of NFPA 101 section 21.2.9.2 and 7.9.2.3, and 1999 Edition of NFPA 110 6-4.2 and 6-4.2.2. 2 " Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. "
And section 6.4.2.2 " Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours."

This deficiency effected 4 of 4 smoke compartments