HospitalInspections.org

Based on observation and staff interview, the facility does not provide a firewall with at least a two-hour fire resistance rating between the nursing home and assisted living portion of the facility. Unsealed penetrations compromise the fire-resistance rating of the firewall, increasing the spread of fire and smoke. The deficient practice affects 2 of 14 smoke zones. The facility has a capacity of 25 with a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM it is observed the 2 hour wall according to the facility code foot print is not complete. The wall is missing in large sections, the door in the 2 hour wall is not a rated door, the door does not have wired glass, only tempered safety glass. There are also open wire chases's in the wall and gaps around wires between the 3rd floor Clinic and Nurse desk area. There is also two other doors that are not rated for this 2 hour wall.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than 2 hours as provided for additions in 18/19.1.1.4. 2000 NFPA 101, 18/19.1.2.3

Based on observation, record review and staff interview, the facility is not providing a one-hour rated ceiling throughout the facility. The building is composed of protected wood frame construction and is required by the Life Safety Code to maintain one-hour fire rated ceilings to protect the attic spaces, if used for healthcare occupancy. This deficient practice affects 1 of 14 smoke zones. This facility has a capacity of 25 and a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM it is observed there is a ceiling tile out by the 2nd floor Kitchenette.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: One story is permitted with complete sprinkler coverage and one-hour rated ceilings for all parts of a facility composed of wood frame construction, type V (111). 2000 NFPA 101, table 18/19.1.6.2

Based on observation and staff interview, the facility failed to provide separation of corridors from use areas. This deficient practice would allow smoke and fire products to travel from the use area into the exit corridor, affecting 2 of 14 smoke zones. This facility has a capacity of 25 and a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM the following is observed:

--1) there are holes in the corridor wall above the ceiling tiles on the 4th floor at ER 1 and ER 2.
--2) There is a gap around blue computer wires on the side wall of the corridor on the 1st floor by room 109 above the ceiling tiles.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, and shall have a fire resistance rating of not less than 1/2 hour. Exception: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system, a corridor shall be permitted to be separated from all other areas by non-rated partitions and terminate at the ceiling if the ceiling is constructed to limit the transfer of smoke. Exception: Existing corridor partitions shall be permitted to terminate at ceilings that are not an integral part of a floor construction if 5 ft or more of space exists between the top of the ceiling subsystem and the bottom of the floor or roof above, provided that the ceiling is a fire-rated assembly tested to have a fire resistance rating of not less than 1 hour in compliance with the provisions of 8.2.3.1. 2000 NFPA 101, 19.3.6.2

Based on observation and staff interview, the facility failed to assure that corridor doors close tightly to prevent gaps, allowing the spread of smoke and fire. This affects 3 of 14 smoke zones. The facility has a capacity of 25 with a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM the following is observed:

--1) There are corridor doors that do not latch to the door frame to room 216, 1st floor Mail room
--2) There is a sitting stool and a door that is obstructing the corridor door from being closed in one motion to 4th floor X-ray Dark room.
--3) The self closer is not latching the door to the door frame to the 2nd floor Kitchenette.

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 is not assuring that one of four smoke barriers is free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects 8 of 14 smoke zones. This facility has a capacity of 25 and a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM the following is observed:

--1) There is a gap around black wires and a pipe and a 1" X 1" hole missing in the lower section of the sheet rock of the 2nd floor by room 220.
--2) There are sheet rock seams that are not sealed, gaps around conduits and wires to the 1st floor smoke wall by room 110.
--3) There are holes in the sheet rock, corner edges of the sheet rock are not sealed, there is a 2" in diameter circle cut in the wall where wires are ran through the wall, and gaps around wires in the 1st floor smoke barrier wall by room 114.
--4) There are two (2) open wire chases in the 3rd floor 2 hour wall that enters into the Clinic.

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 3 of 14 smoke zones. This facility has a capacity of 25 and a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM the following is observed:

--1) There are self closing devices not latching the door to the door frame to Labor & Delivery Storage room, 2nd floor Dirty Utility, Basement Med Gas storage and storage in 215.
--2) There is no self closing device and the South wall is not to the roof deck in the non-sprinkled Basement Material Management storage room.

Maintenance Staff A was present and acknowledged the finding.

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

Based on observation and staff interview the facility fails to assure there is normal illumination in all exit corridors, failing to ensure that all areas of egress will not be left in total darkness. This deficient practice affects in 1 of 14 smoke zones. The facility has a capacity of 25 and a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM it is observed there is no normal illumination in the Dialysis exit corridor. All overhead lights can be turned off with a manual switch.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4

Based on observation and staff interview the facility fails to assure directional and exit signs are properly displayed. This deficient practice fails to direct occupants to a safe path of egress in case of an emergency, affecting 1 of 14 smoke zones. The facility has a capacity of 25 and a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM it is observed the exit sign directional arrows point to a non-exit on the 2nd floor by the CNA Work room.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent. 2000 NFPA 101, 7.10.2

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 and affects 14 of 14 smoke zones.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM it is observed there is no scenario recorded on fire drills conducted in Jan '11, Feb '11, June '11, Sept '11 and Dec '11.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based on record review and staff interview, the facility failed to maintain the smoke detection system in accordance with NFPA 72. .This deficient practice may prevent the prompt initiating of smoke detectors alerting the residents and staff to smoke products due to the devices being out of calibration, affecting 1 of 14 smoke zones. The facility has capacity of 25 and a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM it is observed there is a smoke detector within direct air flow of a ventilation duct in Dialysis.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow nor closer than 3 feet from an air supply or return. 1999 NFPA 72, 2-3.5.1

Based on record review and staff interview, the facility failed to assure that the sprinkler system is maintained and tested in accordance with 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 2 of 14 smoke zones. The facility has the capacity for 25 with a census of 12.

Findings include:
During the tour on 1/25/12 between 11:30 AM and 5:00 PM the following is observed:
--1) There is no documentation of visual monthly checks on the partial sprinkler system.
--2) There is heat tape wrapped around the sprinkler pipe in the Red Tub room.
--3) There is oil dripping onto the FDC (fire dept connection) from a vacuum line that is coming from inside the Boiler room to the outside wall where the FDC is located.
Maintenance Staff A was present and acknowledged the finding.
NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based on observation and staff interview the facility failed to ensure that the means of egress are continuously maintained free of all obstructions or impediments, which would prevent full instant use of the means of egress in the case of a fire or other emergency. This deficiency affects 2 of 12 smoke zones. This facility has a capacity of 25 with a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM it is observed there are chairs and a table obstructing the exit corridor in Dialysis and Physical Therapy.

Maintenance Staff A was present and acknowledged the finding.

NFPA standards: No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1

Based on observation and staff interview the facility failed to ensure that empty and full oxygen cylinders were not stored in the same rack. This deficient practice could cause an empty cylinder to be retrieved in an emergency situation, affecting 2 of 14 smoke zones. The facility has a capacity 25 and a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM the following is observed:

--1) There is an oxygen tank that is not secured on the bottom shelf of the gurney on the 4th floor Surgery.
--2) There is an empty oxygen bottle stored in the full oxygen rack in the 4th floor Surgery Tank room.

Maintenance Staff A was present and acknowledged the finding.

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

Based on observation and staff interview the facility failed to ensure that extension cords and
power strips are not being used as permanent wiring. This deficient practice could cause an electrical fire or the equipment to fail in the event the equipment overloads the capacity of the power strip or extension cord, affecting 5 of 14 smoke zones. This facility has a capacity of 25 and a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM the following is observed:

--1) There is a refrigerator plugged into a power strip in the Lab office.
--2) There is a microwave plugged into a power strip in the Lab office and FCC Break room.
--3) There is a power strip plugged into another power strip in the Lab office.
--4) There is an open junction box in the Electrical room, Chiller room and above the ceiling tiles on 2nd floor in the corridor by the Nursery door.
--5) There is an extension cord plugged into another extension cord in the Rud Tub room.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8

Based on observation and staff interview, the facility does not provide a firewall with at least a two-hour fire resistance rating between the nursing home and assisted living portion of the facility. Unsealed penetrations compromise the fire-resistance rating of the firewall, increasing the spread of fire and smoke. The deficient practice affects 2 of 14 smoke zones. The facility has a capacity of 25 with a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM it is observed the 2 hour wall according to the facility code foot print is not complete. The wall is missing in large sections, the door in the 2 hour wall is not a rated door, the door does not have wired glass, only tempered safety glass. There are also open wire chases's in the wall and gaps around wires between the 3rd floor Clinic and Nurse desk area. There is also two other doors that are not rated for this 2 hour wall.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than 2 hours as provided for additions in 18/19.1.1.4. 2000 NFPA 101, 18/19.1.2.3

Based on observation, record review and staff interview, the facility is not providing a one-hour rated ceiling throughout the facility. The building is composed of protected wood frame construction and is required by the Life Safety Code to maintain one-hour fire rated ceilings to protect the attic spaces, if used for healthcare occupancy. This deficient practice affects 1 of 14 smoke zones. This facility has a capacity of 25 and a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM it is observed there is a ceiling tile out by the 2nd floor Kitchenette.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: One story is permitted with complete sprinkler coverage and one-hour rated ceilings for all parts of a facility composed of wood frame construction, type V (111). 2000 NFPA 101, table 18/19.1.6.2

Based on observation and staff interview, the facility failed to provide separation of corridors from use areas. This deficient practice would allow smoke and fire products to travel from the use area into the exit corridor, affecting 2 of 14 smoke zones. This facility has a capacity of 25 and a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM the following is observed:

--1) there are holes in the corridor wall above the ceiling tiles on the 4th floor at ER 1 and ER 2.
--2) There is a gap around blue computer wires on the side wall of the corridor on the 1st floor by room 109 above the ceiling tiles.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, and shall have a fire resistance rating of not less than 1/2 hour. Exception: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system, a corridor shall be permitted to be separated from all other areas by non-rated partitions and terminate at the ceiling if the ceiling is constructed to limit the transfer of smoke. Exception: Existing corridor partitions shall be permitted to terminate at ceilings that are not an integral part of a floor construction if 5 ft or more of space exists between the top of the ceiling subsystem and the bottom of the floor or roof above, provided that the ceiling is a fire-rated assembly tested to have a fire resistance rating of not less than 1 hour in compliance with the provisions of 8.2.3.1. 2000 NFPA 101, 19.3.6.2

Based on observation and staff interview, the facility failed to assure that corridor doors close tightly to prevent gaps, allowing the spread of smoke and fire. This affects 3 of 14 smoke zones. The facility has a capacity of 25 with a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM the following is observed:

--1) There are corridor doors that do not latch to the door frame to room 216, 1st floor Mail room
--2) There is a sitting stool and a door that is obstructing the corridor door from being closed in one motion to 4th floor X-ray Dark room.
--3) The self closer is not latching the door to the door frame to the 2nd floor Kitchenette.

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 is not assuring that one of four smoke barriers is free of penetrations that compromise the fire-resistance rating of the walls and allow the passage of smoke and fire to another smoke zone. This deficient practice affects 8 of 14 smoke zones. This facility has a capacity of 25 and a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM the following is observed:

--1) There is a gap around black wires and a pipe and a 1" X 1" hole missing in the lower section of the sheet rock of the 2nd floor by room 220.
--2) There are sheet rock seams that are not sealed, gaps around conduits and wires to the 1st floor smoke wall by room 110.
--3) There are holes in the sheet rock, corner edges of the sheet rock are not sealed, there is a 2" in diameter circle cut in the wall where wires are ran through the wall, and gaps around wires in the 1st floor smoke barrier wall by room 114.
--4) There are two (2) open wire chases in the 3rd floor 2 hour wall that enters into the Clinic.

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 3 of 14 smoke zones. This facility has a capacity of 25 and a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM the following is observed:

--1) There are self closing devices not latching the door to the door frame to Labor & Delivery Storage room, 2nd floor Dirty Utility, Basement Med Gas storage and storage in 215.
--2) There is no self closing device and the South wall is not to the roof deck in the non-sprinkled Basement Material Management storage room.

Maintenance Staff A was present and acknowledged the finding.

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

Based on observation and staff interview the facility fails to assure there is normal illumination in all exit corridors, failing to ensure that all areas of egress will not be left in total darkness. This deficient practice affects in 1 of 14 smoke zones. The facility has a capacity of 25 and a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM it is observed there is no normal illumination in the Dialysis exit corridor. All overhead lights can be turned off with a manual switch.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Required illumination shall be arranged so that the failure of any single bulb or unit does not result in less than .2 foot-candles of illumination in any designated area. 2000 NFPA 101, 7.8.1.4

Based on observation and staff interview the facility fails to assure directional and exit signs are properly displayed. This deficient practice fails to direct occupants to a safe path of egress in case of an emergency, affecting 1 of 14 smoke zones. The facility has a capacity of 25 and a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM it is observed the exit sign directional arrows point to a non-exit on the 2nd floor by the CNA Work room.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent. 2000 NFPA 101, 7.10.2

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 and affects 14 of 14 smoke zones.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM it is observed there is no scenario recorded on fire drills conducted in Jan '11, Feb '11, June '11, Sept '11 and Dec '11.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based on record review and staff interview, the facility failed to maintain the smoke detection system in accordance with NFPA 72. .This deficient practice may prevent the prompt initiating of smoke detectors alerting the residents and staff to smoke products due to the devices being out of calibration, affecting 1 of 14 smoke zones. The facility has capacity of 25 and a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM it is observed there is a smoke detector within direct air flow of a ventilation duct in Dialysis.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow nor closer than 3 feet from an air supply or return. 1999 NFPA 72, 2-3.5.1

Based on record review and staff interview, the facility failed to assure that the sprinkler system is maintained and tested in accordance with 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 2 of 14 smoke zones. The facility has the capacity for 25 with a census of 12.

Findings include:
During the tour on 1/25/12 between 11:30 AM and 5:00 PM the following is observed:
--1) There is no documentation of visual monthly checks on the partial sprinkler system.
--2) There is heat tape wrapped around the sprinkler pipe in the Red Tub room.
--3) There is oil dripping onto the FDC (fire dept connection) from a vacuum line that is coming from inside the Boiler room to the outside wall where the FDC is located.
Maintenance Staff A was present and acknowledged the finding.
NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based on observation and staff interview the facility failed to ensure that the means of egress are continuously maintained free of all obstructions or impediments, which would prevent full instant use of the means of egress in the case of a fire or other emergency. This deficiency affects 2 of 12 smoke zones. This facility has a capacity of 25 with a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM it is observed there are chairs and a table obstructing the exit corridor in Dialysis and Physical Therapy.

Maintenance Staff A was present and acknowledged the finding.

NFPA standards: No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1

Based on observation and staff interview the facility failed to ensure that empty and full oxygen cylinders were not stored in the same rack. This deficient practice could cause an empty cylinder to be retrieved in an emergency situation, affecting 2 of 14 smoke zones. The facility has a capacity 25 and a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM the following is observed:

--1) There is an oxygen tank that is not secured on the bottom shelf of the gurney on the 4th floor Surgery.
--2) There is an empty oxygen bottle stored in the full oxygen rack in the 4th floor Surgery Tank room.

Maintenance Staff A was present and acknowledged the finding.

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

Based on observation and staff interview the facility failed to ensure that extension cords and
power strips are not being used as permanent wiring. This deficient practice could cause an electrical fire or the equipment to fail in the event the equipment overloads the capacity of the power strip or extension cord, affecting 5 of 14 smoke zones. This facility has a capacity of 25 and a census of 12.

Findings include:

During the tour on 1/25/12 between 11:30 AM and 5:00 PM the following is observed:

--1) There is a refrigerator plugged into a power strip in the Lab office.
--2) There is a microwave plugged into a power strip in the Lab office and FCC Break room.
--3) There is a power strip plugged into another power strip in the Lab office.
--4) There is an open junction box in the Electrical room, Chiller room and above the ceiling tiles on 2nd floor in the corridor by the Nursery door.
--5) There is an extension cord plugged into another extension cord in the Rud Tub room.

Maintenance Staff A was present and acknowledged the finding.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8