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The facility failed to provide smoke barrier that would provide at least a one hour smoke resistance rating. Findings include:

During the survey, the following are examples of what was observed:

1. 1st floor across from the Surgery Elevator - several blue and yellow wires were observed penetrating the ceiling and going to the floor above. Mineral wool had been placed in the void around the wires, but no fire stop material was observed.
2. 1st floor a 4 "conduit was observed above ceiling across from the Surgery elevator with several blue and yellow wires inside the conduit. End of conduit was not sealed.
This deficiency impacted 3 of 6 smoke compartments. Failure to maintain smoke compartments increases the risk of death or injury due to fire.
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2000 NFPA 101, 8.3.6.1
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The facility failed to provide readily accessible exits at all times per code. Findings include:

During the survey, the following are examples of what was observed:

The following doors were observed with two releasing operations:
1. Ultrasound
2. X-Ray room 106, the door to restroom
3. X-Ray room 106, the door to room labeled private
4. Central Storage

This deficiency impacted 1 of 6 smoke compartments. Failure to maintain exit access increases the risk of death or injury due to fire.
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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.
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The facility failed to conduct sensitivity testing of the smoke detectors per code. Findings include:

During the survey, the following is an example of what was observed:

The facility failed to provide documentation of the required sensitivity test for the smoke detectors. The last documented sensitivity test provided was for June 2012.

This deficiency impacted all smoke dectectors in the facility. Failure to maintain smoke detectors increases the risk of death or injury due to fire.
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1999 NFPA 72, 7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
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Sprinkler coverage was observed during the survey not adequately provided. Findings include:

During the survey, the following are examples of what was observed:

1. Build up of paint on the deflector of a sprinkler in the East Mechanical Room first floor.
2. Build of materials around the deflector of a sprinkler in the Main Boiler Room.
3. 3 ceiling tiles missing in the bagged trash room only.

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1999 NFPA 25, 2-2.1.1 and 2-4.1.2 Sprinklers that are painted, corroded or damaged shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.
NFPA 13 5-6., Sprinklers shall be arranged to be in compliance.

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27382

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The facility failed to maintain the required automatic sprinkler system coverage per code. Findings include:

During the survey, the following is an example of what was observed:

Between the Administrators office and another office a closet was observed without sprinkler coverage inside the closet.

This deficiency impacted 1 of 6 smoke compartments. Failure to maintain the automatic sprinkler system increases the risk of death or injury due to fire.
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2000 NFPA 101, 19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

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1) The facility failed to maintain proper emergency lighting at the generator set and controls. Findings include:

During the survey, the following is an example of what was observed:

One of the four battery-powered lights were inoperable in the generator set and controls room.
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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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27382

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2) The facility failed to maintain required visual and audible alarm notification for generator status per code. A lamp test was conducted prior to testing generator and surveyor observed all lamps illuminated when test button was depressed. Findings include:

During the survey, the following are examples of what was observed:

The facility failed to maintain the following required visual and audible alarm notifications for the generator at the generator and at a remote annunciator:
1. " Not in Auto "
2. " Emergency Stop "
3. " EPS Transfer "

This deficiency impacted 6 of 6 smoke compartments. Failure to maintain the generator increases the risk of death or injury due to fire.
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1999 NFPA 99, 3-4.1.1.15 + Alarm Annunciator. 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 approved electrical utilities. Findings include:

During the survey, the following is an example of what was observed:

1. An electrical panel in the mechanical room/riser room had open blanks.

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1999 NFPA 70, 373-4 Unused opening shall be effectively closed to afford protection substantially equivalent to that of the enclosures.

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27382

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2. At the entrance doors to the Geri-Psych Unit, on the left side above ceiling there was an electrical junction box missing a cover plate.

This deficiency impacted 1 of 6 smoke compartments. Failure to maintain the electrical utilities increases the risk of death or injury due to fire.
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1999 NFPA 70, 370-25 and 410-12. Each box in completed installations to have a cover, face plate, or fixture canopy.
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