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The facility failed to maintain the interior finish for rooms per code. Findings include:

During the survey, the following is an example of what was observed:
The new Electrical/Transfer Switch Room was observed with plywood on the exterior walls, the facility failed to provide flame spread documentation

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2000 NFPA 101, 19.3.3.2 Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted as follows:
(1) Existing materials - Class A or Class B
Exception: In rooms protected by an approved, supervised automatic sprinkler system, existing Class C interior finish shall be permitted to be continued to be used on walls and ceilings within rooms separated from the exit access corridors in accordance with 19.3.6.
(2) Newly installed materials - Class A
Exception No. 1: Newly installed walls and ceilings shall be permitted to have Class A or Class B interior finish in individual rooms having a capacity not exceeding four persons.
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The facility failed to maintain the corridor walls in a non sprinklered section of the facility per code. Findings include:

During the survey, the following are examples of what was observed:
The following corridor walls have the following unsealed penetrations:
1. Group of blue wires at the elevator across from New Direction's Nurses' Station
2. Med. Surge Nurses' Station's Charting Room the back "corridor" wall - red and black wires where wall and deck meet
3. At rooms 135 and 136:
a. two unsealed wiremold ends
b. one black wire
4. Rooms 137 - 143 - electrical junction boxes with unsealed penetrations of wires

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2000 NFPA 101, 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.
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The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following is an example of what was observed.

The Pharmacy and Respiratory Therapy have dutch doors. When the doors were closed this surveyor was able to see into the rooms from the corridor.
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LSC 2000 Edition 19.3.6.3.6 Dutch doors shall be permitted where they conform to 19.3.6.3 In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edge of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel.

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The facility failed to provide exit signs per code. Findings include:

During the survey, the following is an example of what was observed:
No exit sign was provided at the two hour fire barrier for "New Direction" from the old I.C.U. waiting room

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2000 NFPA 101, 7.10.1.4 Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
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The facility failed to maintain the smoke barrier per code. Findings include:

During the survey, the following is an example of what was observed:
The smoke barrier in room 146 had an unsealed penetration of a flex conduit

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2000 NFPA 101, 8.2.4.4.1

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The facility failed to provide/maintain separation of hazardous areas. Findings include: During the survey, the following are examples of what was observed.

1. Mechanical Room E-6 had unsealed penetrations around a sprinkler line in the wall.

2. The combustible storage room 100 sq. ft located across the corridor from the Business Office, door was not equipped with a self-closing device.
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NFPA 101, 19.3.2.1 and 8.4.1 Hazardous areas to be provided with smoke-resisting partitions and doors when protection consists of an automatic extinguishing system. Doors shall be selfclosing with positive latching hardware.

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The facility failed to maintain the exit enclosures per code. Findings include:

During the survey, the following is an example of what was observed:
The stairwell in the basement near Central Supply was observed with an unsealed penetration

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2000 NFPA 101, 8.2.5.2 Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.
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The facility failed to maintain the exit access per code. Findings include:

During the survey, the following are examples of what was observed:
1. The following doors were observed with more than one releasing operation:
a. Patient room 117
b. Patient Room 113
c. Patient room 111 (respiratory/EKG)
d. Room 109 (Dr's Office)
e. Room 108 (Dr's Office)
f. Out Patient Registration
2. The two closets in the Business Office were observed to have padlocks

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2000 NFPA 101, 7.2.1.5.4 A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
2000 NFPA 101, 7.1.9 Any device or alarm installed to restrict the improper use of a means of egress shall be designed and installed so that it cannot, even in case of failure, impede or prevent emergency use of such means of egress unless otherwise provided in 7.2.1.6 and Chapters 18, 19, 22, and 23.
2000 NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
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The facility failed to maintain the horizontal exit per code. Findings include:

During the survey, the following is an example of what was observed:
1. The two hour fire barrier at the Old I.C.U. Waiting Room was observed with the following unsealed penetrations:
a. Several unsealed penetrations
b. Five conduits
c. Vents in the barrier - no dampers
e. "I" beams
f. Not sealed at roof deck
g. Wood stud at the top of the barrier - not two hour rated
2. The two hour fire barrier in the Mech. Room at E.R. had several unsealed penetrations

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2000 NFPA 101, 8.2.3.2.4.2 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:a. It shall be made on either side of the fire barrier.b. It shall be made by an approved device that is designed for the specific purpose.

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The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, the following are examples of what was observed.

1. The exit discharge from the exit by patient room 154 had a single bulbed light fixture.

2. The exit discharge from the exit by Lab was not equipped with a light fixture.

3. The exit discharge from the exit by patient room 140 had a single bulbed light fixture.
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NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.

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The facility failed to provide proper emergency lighting: Findings include: During the survey, the following is an example of what was observed:

The maintenance director was not able to verify if the exit discharge lighting was on the generators.
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NFPA 101, 7.9.2.3 Emergency generators providing power to emergency lighting systems to be installed per NFPA 110.

7.9.1.1* Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply
For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.

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The facility failed to provide continuously illuminated exit signs. Findings include: During the survey, the following is an example of what was observed.

1. Exit sign was not illuminated over the exit from the general storage room by Lab.


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2. The exit sign at the Old I.C.U. Waiting Room was not illuminated

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2000 NFPA 101, 7.10.5.2 Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
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The facility failed to provide a complete written fire safety plan per code. Findings include:

During the survey, the following is an example of what was observed:
The written fire safety plan, provided by the facility, did not contain all eight requirements, specifically item 6 "evacuation of smoke compartment"

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2000 NFPA 101, 19.7.2.2 A written health care occupancy fire safety plan shall provide for the following: (1) Use of alarms (2) Transmission of alarm to fire department (3) Response to alarms (4) Isolation of fire (5) Evacuation of immediate area (6) Evacuation of smoke compartment (7) Preparation of floors and building for evacuation (8) Extinguishment of fire
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The facility failed to conduct fire drills per code. Findings include:

During the survey, the following are examples of what was observed:
First Shift
12/12/13 - 1:20 pm
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08/15/13 - 10:35 am
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06/25/13 - 2:00 pm
05/15/13 - 1:00pm
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NO DRILL

Second shift
NO DRILL
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09/26/13 - 1:45 p
07/26/13 - 1:45 pm
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04/22/13 - 2:37 pm
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03/15/13 - 2:00 pm
02/21/13 - 3:00 pm
01/17/13 - 3:00 pm

Third Shift
NO DRILLS FOR ANY QUARTER

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2000 NFPA 101, 19.7.1.2
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The facility failed to provide current documentation of the inspection of the fire alarm system. During the survey, the following is an example of what was observed.

Documentation provided for the annual fire alarm system inspection conducted on 11/23/2013, indicated two horn/strobes failed. The facility failed to provide documentation to indicate horn/strobes had been corrected.
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1999 NFPA 72, 7-5.2.2 and Figure 7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be maintained which includes periodic tests and applicable information.

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The facility failed to perform sensitivity testing of the smoke detectors. Findings include:


Documentation provided by the facility during the survey did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

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2000 NFPA 101, 9.6.1.3* The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

2000 NFPA 101, 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

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A) Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following is an example of what was observed.

1. The clean up room in OR had missing ceiling tiles.

2. The side wall sprinkler in the general storage room by the Lab was obstructed, box of files placed against the sprinkler.
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NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.

NFPA 13, 4-6.1.4 Obstruction to Discharge. Automatic sprinklers shall not be obstructed by auxiliary devices, piping, insulation, and so forth, from detecting fire or from proper distribution of water.
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B) The facility failed to perform the required maintenance of the facility sprinkler system. Findings include: During the survey, the following is an example of what was observed:

1. The fire department connection was not provided with an identification sign.


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2. The Business Office was missing ceiling tiles

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

NFPA 25, 1998 Edition, 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

1999 NFPA 13, 5-8.4.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm).

1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.

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Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following is an example of what was observed.

1. The clean up room in OR had missing ceiling tiles.

2. The side wall sprinkler in the general storage room by the Lab was obstructed, box of files placed against the sprinkler.
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NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.

NFPA 13, 4-6.1.4 Obstruction to Discharge. Automatic sprinklers shall not be obstructed by auxiliary devices, piping, insulation, and so forth, from detecting fire or from proper distribution of water.




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The facility failed to maintain the fire extinguishers per code. Findings include:
During the survey, the following is an example of what was observed:

1. The fire extinguishers are mounted 69" on hooks at differ locations throughout the facility.

2. The fire extinguisher in the Lab had not been inspected monthly for 12/2013, 1/2013.


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3. The fire extinguisher in the Finance Office was approximately 6' -0" above finished floor

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1998 NFPA 10, 4-3.1 Fire extinguishers shall be inspected when placed in service and thereafter at approximately 30-day intervals.

1998 NFPA 10, 1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 31/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).
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The facility failed to provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following is an example of what was observed.

The designated smoking area was not provided with noncombustible ashtrays, or metal self-closing containers for disposing of cigarette butts.

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NFPA 101, 19.7.4 Ashtrays of noncombustible material and safe design, and metal self-closing containers for disposing of cigarette butts and ashes from ashtrays, shall be provided.

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The facility failed to prohibit portable space heating devices per code. Findings include:

During the survey, the following is an example of what was observed:
A portable space heating device was observed plugged in, in the Finance Office (Nonsleeping compartment)

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2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212?F (100?C).
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The facility failed to provide a readily accessible means of egress pathway at all times. Findings include: During the survey, the following is an example of what was observed.

The means of egress from the general storage room by Lab was obstructed by tables, chairs, and a cart.
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NFPA 101, 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments for full instant use in case of fire or other emergencies.

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The facility failed to maintain the medical gas storage per code. Findings include:

During the survey, the following are examples of what was observed:
The following rooms were observed with unsecured oxygen tanks:
1. Med. Surge Utility Room by room 130 - two tanks
2. New Direction's Doctor's Office - one large tank

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1999 NFPA 99, 4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers - Level 1.
(a) * Handling of Gases. Administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility.
(b) Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed:
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
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The facility failed to provide proper emergency lighting at the generator set and controls. Findings include: During the survey, the following is an example of what was observed.

The battery-powered light in the generator set and controls room was inoperable.

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1999 NFPA 99, 3-6.1.1 and 3-4.1.1.4, and 1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting.

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Facility failed to meet the requirements for the operation of the generator. Findings include: During the survey, the following is an example of what was observed.

1. Documentation was not provided for the weekly inspection of the generator.

2. Documentation was not provided for the monthly load testing of the diesel generator.
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NFPA 101, 19.2.9.1, 7.9 and NFPA 110, 6-4.1 Weekly inspection of the generator.

NFPA 110, 6-3.4 A written record of inspections, tests, exercising, operation, and repairs shall be maintained.

The generator shall meet the requirements outlined in NFPA 99, 3-.4.4.1 and NFPA 110.

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The facility failed to maintain the generator per code. Findings include:

During the survey, the following is an example of what was observed:
During the generator testing, the indicating lamps at the remote annunciator did not illuminate for:
1. "Engine Running"
2. "EPS Supplying load"

The generator remote annunciator panel indicating lamps did work when the test button on the panel was pushed.

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1999 NFPA 99, 3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]
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The facility failed to provide receptacles for appliances. findings include: During the survey, the following are examples of what was observed.

1. A junction box was missing the cover in the boiler room over the air compressor.

2. A microwave was plugged into a circuit breaker protected power strip ( an extension cord ) in the Nurse's lounge. ( Not plugged directly into the wall outlet.)

3. A microwave was plugged into a circuit breaker protected power strip (an extension cord ) in the Business office break room. ( Not plugged directly into the wall outlet.)

4. A circuit breaker protected power strip was plugged into an extension cord in the general storage room by the Lab.


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5. The Business Office had a piece of computer equipment plugged into a surge protector (extension cord), plugged into another surge protector (extension cord) - ran above the ceiling tile

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Appliances, such as air conditioners, microwave and refrigerators, shall plug directly into a receptacle. 1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99.

1999 NFPA 70, Article 240-4, and HCFA Transmittal Notice 22-99 prohibit the use of extension cords without overcurrent protection.

1999 NFPA 70, 400-7 and 400-8, and HCFA Transmittal Notice 22-99 The 1984 edition of the National Electric Code restricts the use of extension cords to temporary short term uses. It is the policy of HCFA to prohibit non-circuit breaker protected extension cords in health care. The limited use of circuit breaker protected power strips is acceptable, provided the current is limited to 15 amps or less, and no major appliances such as air conditioners, refrigerators, or heating units are connected to the power strip.

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The facility failed to provide a fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
The fire watch policy did not contain all of the requirements per code:
1. Notifying the authority having jurisdiction
2. Performing rounds every 15 - 30 minutes
3. The fire watch person shall do nothing else

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2000 NFPA 101, 9.6.1.8
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The facility failed to provide a fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
The fire watch policy did not contain all of the requirements per code:
1. Notifying the authority having jurisdiction
2. Performing rounds every 15 - 30 minutes
3. The fire watch person shall do nothing else

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2000 NFPA 101, 9.6.1.8

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