HospitalInspections.org

Based on observation and staff interview the facility is not ensuring that room doors latch properly and fit tightly into the frame. This deficient practice prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting six of twelve total smoke zones. This facility has a capacity of 99 and a census of 17.
Findings Include:

During the tour from 12/7/15 to 12/7/15 it is noted that:

1. At 1:05 PM on 12/7/15 ½ " gap between door and frame of corridor door #329.
2. At 1:07 PM on 12/7/15 ½ " gap between door and frame of corridor door #326.
3. At 12:07 PM on 12/7/15 3 center stairwell corridor door failed to latch when tested.
4. At 12:07 PM on 12/7/15 ½ " gap between corridor door leafs of door FM1070.
5. At 12:50 PM on 12/8/15 (x2) ½ " holes through ER clean linen corridor door.

The facilities manager was present during the findings.

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 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 staff interview the facility fails to maintain smoke barriers to at least one half hour fire resistance and ensure that all penetrations are properly sealed. This deficient practice would prevent containment of fire and smoke, affecting nine of twelve smoke zones. This facility has a capacity of 99 and a census of 17.

Findings Include:

During the tour from 12/7/15 to 12/8/15 it is noted that:

1. At 1:20 PM on 12/7/15 1 " unsealed penetration around IT cabling in 3rd floor mechanical room above door.
2. At 1:24 PM on 12/7/15 1 " unsealed gap around penetration #156 in 3 south.
3. At 1:32 PM on 12/7/15 (x4) ½ " unsealed gaps around IT wiring bundles on the north side of 3 north corridor doors.
4. At 2:15 PM on 12/7/15 unsealed ½ " gap around IT wiring bundle #198 above doors FM1068 north side.
5. At 2:17 PM on 12/7/15 unsealed ½ " gap around IT wiring bundle #648 above doors FM1068 north side.
6. At 2:29 PM on 12/7/15 unsealed ½ " gap around (x4) 2.5 " conduit penetrations through to the floor below.
7. At 3:40 PM on 12/7/15 unsealed 3 " hole in the west side above corridor doors FM1064.
8. At 3:47 PM on 12/7/15 unsealed 2 " gap around black flex conduit in the west side wall above electrical panel of the southwest equipment room.
9. At 1:05 PM on 12/8/15 unsealed 5 " gap between conduit visible above south ER entrance ceiling level.

The facilities manager was present during the findings.

NFPA Standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1.

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting three of twelve total smoke zones. This facility has a capacity of 99 and a census of 17.

Findings Include:

During the tour from 12/7/15 to 12/7/15 it is noted that:

1. At 1:55 PM on 12/7/15 unrated door without closure hardware installed as a pass through door from ICU soiled utility room to janitorial closet.
2. At 4:00 PM on 12/7/15 (x3) unsealed penetrations in the wall and ceiling of 1st floor soiled utility room.
3. At 4:53 PM on 12/7/15 recovery area soiled utility room door failed to latch when tested.

The facilities manager was present during the findings.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

NFPA Standard: Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1 hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42. 2000 NFPA 101, 8.4.1.

Based on observation and staff interview, the facility failed to provide exit access form the northwest OB Unit located on the second floor. This practice is affecting one of twelve total smoke zones; the facility has a capacity of 99 and a census of 17.
Findings Include:
During the annual survey starting on 12/07/2015 and ending on 12/08/2015 it is observed that:
1. On 12/07/2015 at approximately 1:30 PM the northwest OB exit door was found to be equipped with an exit sign and equipped with a magnetic locking device preventing occupants from exiting the building unless they had special knowledge of how the lock operated. The facility manager stated the only means to exit from the unit, at this exit door, was for the nursing staff to be alerted by a push button device which alerted the nursing staff that someone was needing out of the unit. The nurses station which is not constantly monitored by staff which delays the exiting in accordance with NFPA 101 7.1 19.2.1 and constitutes an immediate Jeopardy.
On 12/10/2015 at approximately 8:30 am the facility was advised they needed to initiate a fire watch for this unit, and the magnetic locking device shall be deactivated immediately. At approximately 09:15 am the facility maintenance director advised the magnetic locking device for the Northwest OB stairwell has been disabled and this was verified by on site nursing staff surveyor at approximately 10:23 am. This citation is now abated.

Based on records review and staff interview the facility failed to ensure that battery powered emergency lighting is tested for 90 minutes annually and documented. This deficient practice could result in the lights not operating for the minimum required time in the event of an emergency, affecting all twelve smoke zones. This facility has a capacity of 99 and a census of 17.

Findings Include:

During the tour from 12/7/15 to 12/7/15 it is noted that:

1. At 12:15 AM on 2015 annual emergency light testing documentation not available during document review.
2. At 12:49 PM on 12/8/15 emergency light FM1219 failed to illuminate when tested.

The facilities manager was present during the findings.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3 and 7.10.9

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all twelve smoke zones. This facility has a capacity of 99 and a census of 17.

Findings Include:

During the tour from 12/7/15 to 12/8/15 it is noted that:

1. At 11:30 AM on 12/7/15 1st shift fire drills occurred within an hour of each other on 6/26/15 at 10:15 AM, 7/31/15 at 10:24 AM, 8/31/15 at 11:05 AM, 9/30/15 at 10:38 AM, 10/30/15 at 11:00 AM, 11/30/15 at 10:02 AM.

The facilities manager was present during the findings.

NFPA Standard: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.
When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 19.7.1.2.

Based on observation and interview the facility fails to insure that the facility is protected throughout by an automatic sprinkler system installed in accordance with the 1999 NFPA 13. This deficient practice prevents the facility from being adequately provided with a sprinkler system as required, affecting two of twelve total smoke zones. This facility has a capacity of 99 and a census of 17.

Findings Include:

During the tour from 12/7/15 to 12/7/15 it is noted that:

1. At 2:43 PM on 12/7/15 no sprinkler coverage provided in OB doctors lounge.
2. At 3:11 PM on 12/7/15 no sprinkler coverage provided in 2nd floor center IT server room.

The facilities manager was present during the findings.

NFPA Standard: Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. 2000 NFPA 101, 9.7.1.1.

NFPA Standard: Automatic sprinkler systems installed to make use of an alternative permitted by this Code shall be considered required systems and shall meet the provisions of this Code that apply to required systems. 2000 NFPA 101, 9.7.1.4.

NFPA Standard: The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5 13.1, 5 13.2, and 5 13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5 6.4.1, 5 7.4.1, 5 8.4.1, 5 9.4.1, 5 10.4.1, and 5 11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections. 1999 NFPA 13, 5 1.1.

NFPA Standard: Electrical Equipment. Sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
Exception: Sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry type electrical equipment is used.
(c) Equipment is installed in a 2 hour fire rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room. 1999 NFPA 13, 5 13.11.

Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting all twelve smoke zones. This facility has a capacity of 99 and a census of 17.

Findings Include:

During the tour from 12/7/15 to 12/7/15 it is noted that:

1. At 10:43 AM on 12/7/15 Sprinkler 2015 2nd, 3rd and 4th quarter inspections documentation not available during document review.
2. At 10:49 AM on 12/7/15 2014 annual inspection documentation not available during document review.
3. At 10:52 AM on 12/7/15 no flow alarm activation times recorded for quarterly sprinkler testing.

The facilities manager was present during the findings.

NFPA Standard: 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. 2000 NFPA 101, 4.6.12.1.

NFPA Standard: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2000 NFPA 101, 9.7.5.

NFPA Standard: Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly. 1998 NFPA 25, 2-3.3.1.

NFPA Standard: Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector ' s test connection. Fire pumps shall not be turned off during testing unless all impairment procedures contained in Chapter 11 are followed.
Exception: Where freezing weather conditions or other circumstances prohibit use of the inspector ' s test connection, the bypass connection shall be permitted to be used. 1998 NFPA 25, 2-3.3.

Based on observation, staff interview and record review, the facility failed to ensure that electrical power for appliances under the kitchen exhaust hood system are arranged to have their power automatically interrupted during activation of the fixed fire extinguishing system as required in NFPA 96, affecting one of twelve total smoke zones. This facility has a capacity of 99 and a census of 17.

Findings Include:

During the tour from 12/7/15 to 12/7/15 it is noted that:

1. At 11:40 AM on 12/7/15 hood suppression system provided for serving line is not tied into fire alarm system or have required fuel shutoff installed.

The facilities manager was present during the findings.

NFPA Standard: Where a fire alarm signaling system is serving the occupancy where the extinguishing system is located, the activation of the automatic fire-extinguishing system shall activate the fire alarm signaling system. 1998 NFPA 96, 7-6.2
NFPA Standard: The operation of an automatic fire suppression system installed within the protected premises shall cause an alarm signal at the protected premises fire alarm control unit and shall be connected to its own zone. 1999 NFPA 72, 3-8.3.2.5.1
NFPA Standard: The integrity of each fire suppression system actuating device and its circuit shall be supervised in accordance with 1-5.8.1 and with other applicable NFPA standards. 1999 NFPA 72, 3-8.3.2.5.2

Based on record review and staff interview the facility failed to assure that portable space heaters are being used within the facility in appropriate areas. This deficient practice could cause a fire due to excessive heat, affecting one of twelve total smoke zones. This facility has a capacity of 99 and a census of 17.

FINDINGS INCLUDE:
During the tour from 12/7/15 to 12/7/15 it is noted that:

1. At 4:50 PM on 12/7/15 portable space heater observed below nursing station desk in the surgery recovery room.

The facilities manager was present during the findings.
NFPA Standard: Prohibits the use of portable space heating devices in non-resident and staff sleeping areas with heating elements that exceed 212 degrees. 2000 NFPA 101, 18/19.7.8

Based on observation and staff interview, the facility failed to assure the proper storage of oxygen tanks. This deficient practice does not assure that medical gas storage is protected in accordance with NFPA 99, affecting two of twelve total smoke zones. This facility has a capacity of 99 and a census of 17.

Findings Include:

During the tour from 12/7/15 to 12/7/15 it is noted that:

1. At 4:55 PM on 12/7/15 mixed full and empty oxygen cylinders stored together in north scope room.
2. At 12:22 PM on 12/8/15 (x2) unsecured oxygen cylinders in MRI 3 scanning office.

The facilities manager was present during the findings.
NFPA Standard: Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. 1999 NFPA 99, 4.3.1.1.2
NFPA Standard: If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. 1999 NFPA 99, 4-3.5.2.2(a)(2)

Based on observation, staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being available at the time of a power loss, affecting all twelve smoke zones. This facility has a capacity of 99 and a census of 17.


Findings Include:

During the tour from 12/7/15 to 12/7/15 it is noted that:

1. At 1:45 PM on 12/8/15 no remote emergency generator shutoff provided.

The facilities manager was present during the findings.

NFPA Standard: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. 1999 NFPA 110 3-5.5.6*
NFPA Standard: For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. 1999 NFPA 110 A-3-5.5.6

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting five of twelve total smoke zones. This facility has a capacity of 99 and a census of 17.

Findings Include:

During the tour from 12/7/15 to 12/7/15 it is noted that:

1. At 1:21 PM on 12/7/15 junction box lacking approved cover in 3rd floor mechanical room along the southwest wall.
2. At 4:17 PM on 12/7/15 junction box lacking approved cover in fire panel room along the ceiling in the northwest corner.
3. At 4:30 PM on 12/7/15 open slot in electrical panel K-1-Left.
4. At 4:34 PM on 12/7/15 open slot in electrical panel NP8 PNL #1 center.
5. At 4:35 PM on 12/7/15 open slots (x2) in electrical panel EC-1-left.
6. At 12:27 PM on 12/8/15 open slots in electrical panels R-2, R-5.
7. At 12:30 PM on 12/8/15 open junction box above ceiling level near elevator B.
9. At 12:35 PM on 12/8/15 open junction box above ceiling level near FM0676.
10. At 12:37 PM on 12/8/15 open junction box in 1st floor north mechanical room near main entrance door.

The facilities manager was present during the findings.
NFPA standard: All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 379-22, Exception. 1999 NFPA 70, 370-28(3)(c).

Based on observation and staff interview the facility is not ensuring that room doors latch properly and fit tightly into the frame. This deficient practice prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting six of twelve total smoke zones. This facility has a capacity of 99 and a census of 17.
Findings Include:

During the tour from 12/7/15 to 12/7/15 it is noted that:

1. At 1:05 PM on 12/7/15 ½ " gap between door and frame of corridor door #329.
2. At 1:07 PM on 12/7/15 ½ " gap between door and frame of corridor door #326.
3. At 12:07 PM on 12/7/15 3 center stairwell corridor door failed to latch when tested.
4. At 12:07 PM on 12/7/15 ½ " gap between corridor door leafs of door FM1070.
5. At 12:50 PM on 12/8/15 (x2) ½ " holes through ER clean linen corridor door.

The facilities manager was present during the findings.

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 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 staff interview the facility fails to maintain smoke barriers to at least one half hour fire resistance and ensure that all penetrations are properly sealed. This deficient practice would prevent containment of fire and smoke, affecting nine of twelve smoke zones. This facility has a capacity of 99 and a census of 17.

Findings Include:

During the tour from 12/7/15 to 12/8/15 it is noted that:

1. At 1:20 PM on 12/7/15 1 " unsealed penetration around IT cabling in 3rd floor mechanical room above door.
2. At 1:24 PM on 12/7/15 1 " unsealed gap around penetration #156 in 3 south.
3. At 1:32 PM on 12/7/15 (x4) ½ " unsealed gaps around IT wiring bundles on the north side of 3 north corridor doors.
4. At 2:15 PM on 12/7/15 unsealed ½ " gap around IT wiring bundle #198 above doors FM1068 north side.
5. At 2:17 PM on 12/7/15 unsealed ½ " gap around IT wiring bundle #648 above doors FM1068 north side.
6. At 2:29 PM on 12/7/15 unsealed ½ " gap around (x4) 2.5 " conduit penetrations through to the floor below.
7. At 3:40 PM on 12/7/15 unsealed 3 " hole in the west side above corridor doors FM1064.
8. At 3:47 PM on 12/7/15 unsealed 2 " gap around black flex conduit in the west side wall above electrical panel of the southwest equipment room.
9. At 1:05 PM on 12/8/15 unsealed 5 " gap between conduit visible above south ER entrance ceiling level.

The facilities manager was present during the findings.

NFPA Standard: Requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1.

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting three of twelve total smoke zones. This facility has a capacity of 99 and a census of 17.

Findings Include:

During the tour from 12/7/15 to 12/7/15 it is noted that:

1. At 1:55 PM on 12/7/15 unrated door without closure hardware installed as a pass through door from ICU soiled utility room to janitorial closet.
2. At 4:00 PM on 12/7/15 (x3) unsealed penetrations in the wall and ceiling of 1st floor soiled utility room.
3. At 4:53 PM on 12/7/15 recovery area soiled utility room door failed to latch when tested.

The facilities manager was present during the findings.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

NFPA Standard: Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1 hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42. 2000 NFPA 101, 8.4.1.

Based on observation and staff interview, the facility failed to provide exit access form the northwest OB Unit located on the second floor. This practice is affecting one of twelve total smoke zones; the facility has a capacity of 99 and a census of 17.
Findings Include:
During the annual survey starting on 12/07/2015 and ending on 12/08/2015 it is observed that:
1. On 12/07/2015 at approximately 1:30 PM the northwest OB exit door was found to be equipped with an exit sign and equipped with a magnetic locking device preventing occupants from exiting the building unless they had special knowledge of how the lock operated. The facility manager stated the only means to exit from the unit, at this exit door, was for the nursing staff to be alerted by a push button device which alerted the nursing staff that someone was needing out of the unit. The nurses station which is not constantly monitored by staff which delays the exiting in accordance with NFPA 101 7.1 19.2.1 and constitutes an immediate Jeopardy.
On 12/10/2015 at approximately 8:30 am the facility was advised they needed to initiate a fire watch for this unit, and the magnetic locking device shall be deactivated immediately. At approximately 09:15 am the facility maintenance director advised the magnetic locking device for the Northwest OB stairwell has been disabled and this was verified by on site nursing staff surveyor at approximately 10:23 am. This citation is now abated.

Based on records review and staff interview the facility failed to ensure that battery powered emergency lighting is tested for 90 minutes annually and documented. This deficient practice could result in the lights not operating for the minimum required time in the event of an emergency, affecting all twelve smoke zones. This facility has a capacity of 99 and a census of 17.

Findings Include:

During the tour from 12/7/15 to 12/7/15 it is noted that:

1. At 12:15 AM on 2015 annual emergency light testing documentation not available during document review.
2. At 12:49 PM on 12/8/15 emergency light FM1219 failed to illuminate when tested.

The facilities manager was present during the findings.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3 and 7.10.9

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all twelve smoke zones. This facility has a capacity of 99 and a census of 17.

Findings Include:

During the tour from 12/7/15 to 12/8/15 it is noted that:

1. At 11:30 AM on 12/7/15 1st shift fire drills occurred within an hour of each other on 6/26/15 at 10:15 AM, 7/31/15 at 10:24 AM, 8/31/15 at 11:05 AM, 9/30/15 at 10:38 AM, 10/30/15 at 11:00 AM, 11/30/15 at 10:02 AM.

The facilities manager was present during the findings.

NFPA Standard: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.
When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 19.7.1.2.

Based on observation and interview the facility fails to insure that the facility is protected throughout by an automatic sprinkler system installed in accordance with the 1999 NFPA 13. This deficient practice prevents the facility from being adequately provided with a sprinkler system as required, affecting two of twelve total smoke zones. This facility has a capacity of 99 and a census of 17.

Findings Include:

During the tour from 12/7/15 to 12/7/15 it is noted that:

1. At 2:43 PM on 12/7/15 no sprinkler coverage provided in OB doctors lounge.
2. At 3:11 PM on 12/7/15 no sprinkler coverage provided in 2nd floor center IT server room.

The facilities manager was present during the findings.

NFPA Standard: Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. 2000 NFPA 101, 9.7.1.1.

NFPA Standard: Automatic sprinkler systems installed to make use of an alternative permitted by this Code shall be considered required systems and shall meet the provisions of this Code that apply to required systems. 2000 NFPA 101, 9.7.1.4.

NFPA Standard: The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5 13.1, 5 13.2, and 5 13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5 6.4.1, 5 7.4.1, 5 8.4.1, 5 9.4.1, 5 10.4.1, and 5 11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections. 1999 NFPA 13, 5 1.1.

NFPA Standard: Electrical Equipment. Sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
Exception: Sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry type electrical equipment is used.
(c) Equipment is installed in a 2 hour fire rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room. 1999 NFPA 13, 5 13.11.

Based on record review and staff interviews, the facility failed to assure that the sprinkler system is maintained and tested in accordance with the NFPA 13 and NFPA 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting all twelve smoke zones. This facility has a capacity of 99 and a census of 17.

Findings Include:

During the tour from 12/7/15 to 12/7/15 it is noted that:

1. At 10:43 AM on 12/7/15 Sprinkler 2015 2nd, 3rd and 4th quarter inspections documentation not available during document review.
2. At 10:49 AM on 12/7/15 2014 annual inspection documentation not available during document review.
3. At 10:52 AM on 12/7/15 no flow alarm activation times recorded for quarterly sprinkler testing.

The facilities manager was present during the findings.

NFPA Standard: 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. 2000 NFPA 101, 4.6.12.1.

NFPA Standard: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2000 NFPA 101, 9.7.5.

NFPA Standard: Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly. 1998 NFPA 25, 2-3.3.1.

NFPA Standard: Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector ' s test connection. Fire pumps shall not be turned off during testing unless all impairment procedures contained in Chapter 11 are followed.
Exception: Where freezing weather conditions or other circumstances prohibit use of the inspector ' s test connection, the bypass connection shall be permitted to be used. 1998 NFPA 25, 2-3.3.

Based on observation, staff interview and record review, the facility failed to ensure that electrical power for appliances under the kitchen exhaust hood system are arranged to have their power automatically interrupted during activation of the fixed fire extinguishing system as required in NFPA 96, affecting one of twelve total smoke zones. This facility has a capacity of 99 and a census of 17.

Findings Include:

During the tour from 12/7/15 to 12/7/15 it is noted that:

1. At 11:40 AM on 12/7/15 hood suppression system provided for serving line is not tied into fire alarm system or have required fuel shutoff installed.

The facilities manager was present during the findings.

NFPA Standard: Where a fire alarm signaling system is serving the occupancy where the extinguishing system is located, the activation of the automatic fire-extinguishing system shall activate the fire alarm signaling system. 1998 NFPA 96, 7-6.2
NFPA Standard: The operation of an automatic fire suppression system installed within the protected premises shall cause an alarm signal at the protected premises fire alarm control unit and shall be connected to its own zone. 1999 NFPA 72, 3-8.3.2.5.1
NFPA Standard: The integrity of each fire suppression system actuating device and its circuit shall be supervised in accordance with 1-5.8.1 and with other applicable NFPA standards. 1999 NFPA 72, 3-8.3.2.5.2

Based on record review and staff interview the facility failed to assure that portable space heaters are being used within the facility in appropriate areas. This deficient practice could cause a fire due to excessive heat, affecting one of twelve total smoke zones. This facility has a capacity of 99 and a census of 17.

FINDINGS INCLUDE:
During the tour from 12/7/15 to 12/7/15 it is noted that:

1. At 4:50 PM on 12/7/15 portable space heater observed below nursing station desk in the surgery recovery room.

The facilities manager was present during the findings.
NFPA Standard: Prohibits the use of portable space heating devices in non-resident and staff sleeping areas with heating elements that exceed 212 degrees. 2000 NFPA 101, 18/19.7.8

Based on observation and staff interview, the facility failed to assure the proper storage of oxygen tanks. This deficient practice does not assure that medical gas storage is protected in accordance with NFPA 99, affecting two of twelve total smoke zones. This facility has a capacity of 99 and a census of 17.

Findings Include:

During the tour from 12/7/15 to 12/7/15 it is noted that:

1. At 4:55 PM on 12/7/15 mixed full and empty oxygen cylinders stored together in north scope room.
2. At 12:22 PM on 12/8/15 (x2) unsecured oxygen cylinders in MRI 3 scanning office.

The facilities manager was present during the findings.
NFPA Standard: Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. 1999 NFPA 99, 4.3.1.1.2
NFPA Standard: If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. 1999 NFPA 99, 4-3.5.2.2(a)(2)

Based on observation, staff interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice may prevent the emergency power supply from being available at the time of a power loss, affecting all twelve smoke zones. This facility has a capacity of 99 and a census of 17.


Findings Include:

During the tour from 12/7/15 to 12/7/15 it is noted that:

1. At 1:45 PM on 12/8/15 no remote emergency generator shutoff provided.

The facilities manager was present during the findings.

NFPA Standard: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. 1999 NFPA 110 3-5.5.6*
NFPA Standard: For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. 1999 NFPA 110 A-3-5.5.6

Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 70, National Electrical Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting five of twelve total smoke zones. This facility has a capacity of 99 and a census of 17.

Findings Include:

During the tour from 12/7/15 to 12/7/15 it is noted that:

1. At 1:21 PM on 12/7/15 junction box lacking approved cover in 3rd floor mechanical room along the southwest wall.
2. At 4:17 PM on 12/7/15 junction box lacking approved cover in fire panel room along the ceiling in the northwest corner.
3. At 4:30 PM on 12/7/15 open slot in electrical panel K-1-Left.
4. At 4:34 PM on 12/7/15 open slot in electrical panel NP8 PNL #1 center.
5. At 4:35 PM on 12/7/15 open slots (x2) in electrical panel EC-1-left.
6. At 12:27 PM on 12/8/15 open slots in electrical panels R-2, R-5.
7. At 12:30 PM on 12/8/15 open junction box above ceiling level near elevator B.
9. At 12:35 PM on 12/8/15 open junction box above ceiling level near FM0676.
10. At 12:37 PM on 12/8/15 open junction box in 1st floor north mechanical room near main entrance door.

The facilities manager was present during the findings.
NFPA standard: All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 379-22, Exception. 1999 NFPA 70, 370-28(3)(c).