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NFPA 101, 19.3.6.3.3 Hold-open devices that release when the door is pushed or pulled shall be permitted.

A.19.3.6.3.3 Door should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual latching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

This STANDARD was not met as evidenced by:

Based on observation the facility failed to ensure that three corridor doors were not impeded from closing.

Findings include:

On 4/18/12 during a tour of the facility, the following doors were observed to be impeded from closing:

1) At 9:45 AM it was observed that the kitchen door to the corridor was held open with a hook-and-eye latching device installed at the base of the door.

2) At 10:15 AM it was observed that a blood pressure machine in Patient Room #118 was recharging from an outlet located in the corridor, impeding the closure of that door.

3) At 10:15 AM it was observed that a soiled linen cart in Patient Room #117 obstructed the closing of that door.

Based on observation the facility failed to ensure that one of six smoke barrier doors was self-closing to resist the passage of smoke from one smoke compartment to another.

Findings include:

On 4/19/12 during a test of the fire alarm system, it was observed that the smoke barrier doors between smoke compartment "A" and smoke compartment "E" were motorized doors, with a default setting to release the magnetic locks and move the doors to the open position when the fire alarm is activated.

This finding was shared with the Administrator and Director of Plant Operations during the exit interview on 4/19/12.

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.

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 National Fire Protection Association (NFPA) 70, National Electric Code, and NFPA 72, National Fire Alarm Code...

NFPA 72 Chapter 10, 10.4.3.2 Sensitivity of smoke detectors and single and multiple-station smoke alarms in other than one and two-family dwellings shall be tested in accordance with 10.4.3.2.1 through 10.4.3.2.6.

10.4.3.2.1. Sensitivity shall be checked within 1 year after installation.

10.4.3.2.1 Sensitivity shall be checked every alternate year thereafter unless other wise permitted by compliance with 10.4.3.2.3.

This STANDARD was not met as evidenced by:

Based on record review and staff interview, the facility failed to ensure that the smoke detectors had the required smoke sensitivity testing.

Findings include:

On 4/18/12 during a review of the facility's maintenance records it was revealed that there was no documentation of the required smoke detector sensitivity testing. On 4/19/12 the Director of Plant Operations was interviewed in regard to the missing documentation, and he indicated that during the seven months he had worked there, he had neither come across documentation, nor was he aware that the smoke detectors had been sensitivity tested.

This finding was shared with the Administrator and the Director of Plant Operations during the exit interview on 4/19/12.

Based on observation the facility failed to ensure that the use of oxygen was prohibited in one of one, designated patient smoking areas; and the facility failed to ensure that the designated smoking area was provided with metal containers with lids, to receive waste from ashtrays.

Findings include:

On 4/18/12 at 10:15 AM a female patient in a wheelchair, on oxygen, was seen in the temporary, designate, patient smoking area with two other people that were smoking. At 12:05 PM the same patient, using oxygen, was seen in the designated smoking area with three to five other people that were smoking.

The temporary, designated, patient smoking area was within ten feet of the exit door, and the door to patient room 117. The area was not provided with metal containers with self-closing covers into which ashtrays could be emptied.

On 4/19/12, during the exit interview, the Administrator acknowledged that the patient's use of oxygen in a designated smoking area had been brought to his attention immediately after it had occurred.

NFPA 90 A, Chapter 3 Integration of a Ventilation and Air-Conditioning System(s) with Building Construction. 3.4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed: all dampers shall be operated to verify that they fully close; the latch, shall be checked; and moving parts shall be lubricated as necessary.

This STANDARD was not met as evidenced by:

Based on record review and staff interview, the facility failed to ensure that the smoke/fire dampers were inspected and serviced on a four-year cycle.

Findings include:

On 4/18/12 during a review of the facility's maintenance records it was revealed that there was no documentation of the required, four-year, servicing and inspection of the fire/smoke dampers. On 4/19/12 the Director of Plant Operations was interviewed in regard to the missing documentation, and he indicated that during the seven months he had worked there he had neither come across documentation, nor was he aware that the dampers were ever inspected or serviced.

This finding was shared with the Administrator and the Director of Plant Operations during the exit interview on 4/19/12.

NFPA 96 Chapter 10 Fire Extinguishing Equipment, 10.2.2
A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire-extinguishing system shall be conspicuously placed near each portable fire extinguisher in the cooking area.

This STANDARD was not met as evidenced by:

Based on observation and staff interview the facility failed to assure that the portable "K" extinguisher in the cooking area had a placard nearby instructing staff to permit the automatic fire-extinguishing system to be the primary defense for grease fires. This kitchen was the major food preparation area for all hospital patients.

Findings include:

On 4/18/2012 it was observed that the required signage for the use of the portable "K" extinguisher was absent. Also, when the Kitchen Manager was asked how he would respond to a grease fire in the kitchen, he indicated that he would first use the portable "K" extinguisher to put it out.

This finding was shared with the Administrator, Director of Plant Operations, and the Kitchen Manager during the exit interview on 4/19/2012.

This STANDARD was not met as evidenced by:

Based on record review and staff interview, the facility failed to ensure that the emergency backup generator was inspected weekly.

Findings include:

On 4/18/12 during a review of the facility's maintenance records it was revealed that the most recent documentation of weekly inspections performed on the generator set were in the year 2009. On 4/19/12 the Director of Plant Operations was interviewed in regard to the missing documentation, and he indicated that during the seven months he had worked there, weekly inspections were not being performed.

This finding was shared with the Administrator and the Director of Plant Operations during the exit interview on 4/19/12.