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The facility failed to ensure the occupancy separation wall between the hospital and the clinic basement was a fire barrier having at least a two-hour fire resistance rating.

Observation determined the vision panel appeared to be tempered glass installed in the 90-minute fire door with no documentation indicating a two-hour fire protection rating.

The facility failed to maintain two-hour fire resistive rated floor/ceiling assemblies throughout the building.

The structural framing of floor/ceiling assemblies in buildings of Type II (222) construction must be two-hour fire resistive rated construction and requires the use of UL listed fire-rated materials to maintain the rating. Observation determined unsealed spaces in the gypsum board ceiling adjacent to a round duct in the north Mechanical Room.

The facility failed to ensure interior finish for corridors and exit ways had a flame spread rating of Class A or Class B.

Records review indicated:
1) No documentation of interior wall finish rating for one (1) folding wall partition in the 2nd floor Activities/Dining Room which was not separated from the corridor.
2) No documentation of the flame spread rating for the carpet applied to the three (3) corridor walls in the alcove by the 1st floor copy machine.

1) The facility failed to ensure exits are arranged to provide a continuous path of escape.

Observation determined the access to the east stair enclosure on the fourth (4th) and fifth (5th) floor was through intervening spaces. The fourth (4th) floor must exit through the Surgical Suite and the fifth (5th) floor must exit through the PT/OT Suite to reach the east stair enclosure.
2) The 5th floor east stair enclosure wall between the PT/OT suite and the stairway terminated at the ceiling.
3) The door installed in the east basement stair enclosure had no label indicating the fire protection rating of the wood door.

The facility failed to ensure all areas had proper coverage by the automatic fire sprinkler system.

Observation determined:

a) The 2nd floor Mechanical Room was not adequately protected by the fire sprinkler system. A sprinkler that protected the area adjacent to the east wall was obstructed by ducts.

b) The sprinklers in the Kitchen Dishwashing Room were not ordinary temperature rated, but were intermediate temperature rated. The sprinklers were green glass bulb color, which was an indication of an intermediate temperature rating. These sprinklers must be used only when the maximum ceiling temperature exceeds 100 deg Fahrenheit. The contents of this room did not warrant treatment as intermediate or extra hazard occupancy and there was no fuel-fired equipment located in this area.

c) The 1st floor Mechanical Room had no sprinkler coverage below a duct that was 57 inches in width. Obstructions greater than 4 feet in width require the addition of a sprinkler below the obstruction.

d) The room behind the basement sterilizer was not adequately protected by the fire sprinkler system. A sprinkler that protected the space was obstructed by a duct.

1) The facility failed to ensure the kitchen automatic extinguishing system was inspected and maintained in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. 19.3.2.6, 9.3

An inspection and servicing of the kitchen fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system must be made at least every 6 months by properly trained and qualified persons. All actuation components, including remote manual pull stations, mechanical or electrical devices, detectors, actuators, and fire-actuated dampers, must be checked for proper operation during the inspection in accordance with the manufacturer's listed procedures.

Records review determined the automatic gas shut-off for the gas fuel supply to the commercial cooking equipment was not tested during one (1) of the previous two (2) inspections by the service contractor. Records review indicated the gas shut-off valve was not tested during the May, 2010 inspection.

2) The facility failed to train staff and post instructions for manually operating the commercial hood fire-extinguishing system.

Maintenance staff indicated new employee orientation and annual training was not provided for Dietary employees regarding instructions to manually activate the fire-extinguishing system.

The facility failed to ensure electric installations in oxygen storage locations comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Observation determined the wall switches for the exhaust fan and ceiling light were installed on the wall less than five feet above the floor. Fixtures, switches, and receptacles must be installed in fixed locations not less than (5 ft) above the floor as a precaution against their physical damage.

The facility failed to ensure anesthetizing locations are protected in accordance with NFPA 99, Standard for Health Care Facilities.

Maintenance staff indicated the relative humidity was not monitored daily prior to surgical procedures but was monitored weekly.

The facility failed to ensure temporary wiring is not used as a substitute for permanent wiring. Multiplug adapters, extension cords, cube adapters, and other devices used as a substitute for permanent wiring shall not be used. NFPA 70, section 6-1.5.

Observation determined an extension cord in use to provide electricity to a sump pump in the basement freight elevator equipment room. When electrical hazards are identified, measures to abate such conditions must be taken.

The facility failed to ensure the occupancy separation wall between the hospital and the clinic basement was a fire barrier having at least a two-hour fire resistance rating.

Observation determined the vision panel appeared to be tempered glass installed in the 90-minute fire door with no documentation indicating a two-hour fire protection rating.

The facility failed to maintain two-hour fire resistive rated floor/ceiling assemblies throughout the building.

The structural framing of floor/ceiling assemblies in buildings of Type II (222) construction must be two-hour fire resistive rated construction and requires the use of UL listed fire-rated materials to maintain the rating. Observation determined unsealed spaces in the gypsum board ceiling adjacent to a round duct in the north Mechanical Room.

The facility failed to ensure interior finish for corridors and exit ways had a flame spread rating of Class A or Class B.

Records review indicated:
1) No documentation of interior wall finish rating for one (1) folding wall partition in the 2nd floor Activities/Dining Room which was not separated from the corridor.
2) No documentation of the flame spread rating for the carpet applied to the three (3) corridor walls in the alcove by the 1st floor copy machine.

1) The facility failed to ensure exits are arranged to provide a continuous path of escape.

Observation determined the access to the east stair enclosure on the fourth (4th) and fifth (5th) floor was through intervening spaces. The fourth (4th) floor must exit through the Surgical Suite and the fifth (5th) floor must exit through the PT/OT Suite to reach the east stair enclosure.
2) The 5th floor east stair enclosure wall between the PT/OT suite and the stairway terminated at the ceiling.
3) The door installed in the east basement stair enclosure had no label indicating the fire protection rating of the wood door.

The facility failed to ensure all areas had proper coverage by the automatic fire sprinkler system.

Observation determined:

a) The 2nd floor Mechanical Room was not adequately protected by the fire sprinkler system. A sprinkler that protected the area adjacent to the east wall was obstructed by ducts.

b) The sprinklers in the Kitchen Dishwashing Room were not ordinary temperature rated, but were intermediate temperature rated. The sprinklers were green glass bulb color, which was an indication of an intermediate temperature rating. These sprinklers must be used only when the maximum ceiling temperature exceeds 100 deg Fahrenheit. The contents of this room did not warrant treatment as intermediate or extra hazard occupancy and there was no fuel-fired equipment located in this area.

c) The 1st floor Mechanical Room had no sprinkler coverage below a duct that was 57 inches in width. Obstructions greater than 4 feet in width require the addition of a sprinkler below the obstruction.

d) The room behind the basement sterilizer was not adequately protected by the fire sprinkler system. A sprinkler that protected the space was obstructed by a duct.

1) The facility failed to ensure the kitchen automatic extinguishing system was inspected and maintained in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. 19.3.2.6, 9.3

An inspection and servicing of the kitchen fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system must be made at least every 6 months by properly trained and qualified persons. All actuation components, including remote manual pull stations, mechanical or electrical devices, detectors, actuators, and fire-actuated dampers, must be checked for proper operation during the inspection in accordance with the manufacturer's listed procedures.

Records review determined the automatic gas shut-off for the gas fuel supply to the commercial cooking equipment was not tested during one (1) of the previous two (2) inspections by the service contractor. Records review indicated the gas shut-off valve was not tested during the May, 2010 inspection.

2) The facility failed to train staff and post instructions for manually operating the commercial hood fire-extinguishing system.

Maintenance staff indicated new employee orientation and annual training was not provided for Dietary employees regarding instructions to manually activate the fire-extinguishing system.

The facility failed to ensure electric installations in oxygen storage locations comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Observation determined the wall switches for the exhaust fan and ceiling light were installed on the wall less than five feet above the floor. Fixtures, switches, and receptacles must be installed in fixed locations not less than (5 ft) above the floor as a precaution against their physical damage.

The facility failed to ensure anesthetizing locations are protected in accordance with NFPA 99, Standard for Health Care Facilities.

Maintenance staff indicated the relative humidity was not monitored daily prior to surgical procedures but was monitored weekly.

The facility failed to ensure temporary wiring is not used as a substitute for permanent wiring. Multiplug adapters, extension cords, cube adapters, and other devices used as a substitute for permanent wiring shall not be used. NFPA 70, section 6-1.5.

Observation determined an extension cord in use to provide electricity to a sump pump in the basement freight elevator equipment room. When electrical hazards are identified, measures to abate such conditions must be taken.