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The facility failed to provide a permitted construction type required by code. During the survey, the following are examples of what was observed, findings include:

1. The North East Hall's corridor was observed with nonrated ceiling tile, nonrated ceiling grid and the light fixtures were not tented. The rooms were observed with a one hour rated ceiling. A corridor smoke detection system was observed. This area does not have an automatic sprinkler system. This area is a nonpermitted construction type of II (000), without a sprinkler system. This area is separated by a two hour wall from the rest of the facility.
2. The North East's exit discharge had a wood frame with visqueen attached to the building for shelter for the smokers. This is a nonpermitted construction type of V (000), without a sprinkler system.


2000 NFPA 101, 19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations
Construction Stories
Type
1 2 3 4 or
More
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
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The facility failed to maintain corridor separation per code. During the survey, the following is an example of what was observed, findings include:

The North East corridor walls were observed not extending to the roof deck. This area did not have an automatic sprinkler system.

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.
Exception No. 1*: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.
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The facility failed to maintain the corridor doors per code. Findings include:
During the survey, the following is an example of what was observed:

The two X-ray corridor doors were observed not having positive latching hardware.

2000 NFPA 101, 19.3.6.3.2 Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
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The facility failed to provide smoke barriers that would provide at least a half hour fire resistance rating. Findings include:

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

A) Unsealed penetrations around a beam and at the end of a sleeve in the Smoke Barrier, inside ER Conference Room.

NFPA 101, 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.


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B) The smoke barrier at the smoke doors at the Conference Room was observed with the following:

1. The barrier did not extend to the roof deck.
2. There was one unsealed penetration.

2000 NFPA 101, 8.3.2 Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
2000 NFPA 101, 8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke 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 smoke barrier, the sleeve shall be solidly set in the smoke 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 smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) 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 smoke 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 separation of hazardous areas. Findings include:

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

The Dietary Combustible Storage Room, over 50 sq. feet, was not provided with a self-closing device for the door.

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 self-closing with positive latching hardware.

The facility failed to provide a sound path of travel for the exit access per code. Findings include: During the survey, the following is an example of what was observed:

The "Time Clock Hall Exit Discharge" was observed with a concrete stoop that ended in a grassy area.

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.
2000 NFPA 101, 7.5.1.1 Exits shall be located and exit access shall be arranged so that exits are readily accessible at all times.
2000 NFPA 101, 7.7.1 Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.
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The facility failed to provide continuous illumination for the means of egress per code. Findings include: During the survey, the following is an example of what was observed:

The "Time Clock Hall Exit Discharge" was observed with a single bulb - single fixture.

2000 NFPA 101, 7.8.1.2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.

The facility failed to maintain the fire alarm system in proper working order.

Findings include:

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

A) While observing the smoke barrier time clock corridor, this surveyor saw a smoke detector laying on top of one of the ceiling tiles. Based upon interview with maintenance, he advised that all ceiling tiles had been replaced in this corridor, and cut in tile had not been made for the smoke detector.

Spacing of corridor smoke detectors of not more than 30 feet on center, nor more than 15 feet from any wall, as required in NFPA 101, 18.3.4.5.3, and 1999 NFPA 72, 2-3.4.5.1.1, was not provided in this building.


B) During the test of the fire alarm system, this surveyor observed the horn/strobe not to be functional in the corridor by Pharmacy and Dietary.

1999 NFPA 72, 4-4.2.1 A maximum pulse duration shall be 0.2 seconds with a maximum duty cycle of 40 percent. The pulse duration shall be defined as the time interval between initial and final points of 10 percent of maximum signal.

1999 NFPA 72, 4-4.2.2* The light source color shall be clear or nominal white and shall not exceed 1000 cd (effective intensity).

1999 NFPA 72, 4-4.3.1 Visible notification appliances used in the public mode shall be located and shall be of a type, size, intensity, and number so that the operating effect of the appliance is seen by the intended viewers regardless of the viewer's orientation.

1999 NFPA 72, 4-4.4.2.3 In corridors where there are more than two visible notification appliances in any field of view, they shall be spaced a minimum of 55 ft (16.76 m) from each other or they shall flash in synchronization.


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C) During the survey, the smoke detector for the smoke doors by the Pharmacy was observed missing.

2000 NFPA 101, 9.6.2.9 Where a partial smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72, National Fire Alarm Code, shall be provided in all common areas and work spaces, such as corridors, lobbies, Storage Rooms, Equipment Rooms, and other tenantless spaces in those environments suitable for proper smoke detector operation. Selective smoke detection unique to other sections of this Code shall be provided as required by those sections.
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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. The escutcheon plate was missing on a sprinkler in the corridor by Pharmacy.

2. The escutcheon plate was missing on a sprinkler in the Staff Restroom Business Corridor.

3. Corrosion build up on all the sprinklers in the Kitchen.

2000 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

1. Bend deflector on a sprinkler in the Old Business/Administation Office.

2. Corrosion build up on all the sprinklers in the Kitchen.

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.

Two sprinklers are flush against the light fixture, two separate locations on the Dietary Loading Dock, causing obstruction of the deflector.

1999 NFPA 13, 5-5.5.2.1 and 5-6.5.2.1. Sprinklers shall be located so as to minimize obstructions to discharge.

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

During the survey, the following are examples of what was observed:
Darlene's Mechanical Room was observed with pendent type sprinkler heads without a ceiling in the room.

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

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

During the survey, the following is an example of what was observed:
The return air grill in the two hour fire rated barrier separating the hospital from the nursing home was observed without a fire damper.

1999 NFPA 90A, 3-3.1.1* Approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more.

1999 NFPA 90A, 3-3.1.2 Approved fire dampers shall be provided in all air transfer openings in partitions that are required to have a fire resistance rating and in which other openings are required to be protected.

1999 NFPA 90A, 3-4.5.4 Dampers shall close against the maximum calculated airflow of that portion of the air duct system in which they are installed. Fire dampers shall be tested in accordance with UL 555, Standard for Safety Fire Dampers. Smoke dampers shall be tested in accordance with UL 555S, Standard for Safety Smoke Dampers.
1999 NFPA 90A, 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
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The facility failed to maintain the dietary hood. Findings include:

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

A) The filters were not tight fitting or firmly held in place, approximatley an half inch gap was between three separate filters.

NFPA 96, 3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tight fitting and firmly held in place.


B) The K-Extinguisher was not provided with a placard identifying use of extinguisher.

NFPA 96 7-2.1.1 A placard identifying the use of the extinguisher as a secondary backup means to the automatic fire suppression system shall be conspicuously placed near each portable fire extinguisher in the cooking area.


C) During survey, the provided documentation for the monthly inspection of the hood system was the inspection card attached to the pull station of the hood extinguishing system. This card was observed with space on the reverse side to date and initial each month an inspection was conducted by facility staff. The side of the inspection card was blank for the month of January 2011.

NFPA 17, 9-2.1- On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or owner's manual. As a minimum, this "quick check" or inspection shall include verification of the following:

(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blow-off caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

The facility failed to maintain the means of egress per code. Findings include:

During the survey, the following is an example of what was observed:
Five chairs were observed in the X-ray corridor obstructing the means of egress.

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.
2000 NFPA 101, 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.
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Documentation was not provided for annual service of the fire hydrants.

NFPA 25, 4-4.3 Hydrants

4-4.3.1 Hydrants shall be lubricated annually to ensure that all stems, caps, plugs, and threads are in proper operating condition.

The facility failed to maintain the generator per code. Findings include: During the survey, the following are examples of what was observed:
The generator remote annunciator was observed not indicating "Line Power" and when the generator was tested, the remote did not indicate "Gen Power".

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 maintain the electrical system per code. Findings include:

During the survey, the following are examples of what was observed:
The Office Manager's Office was observed with:

1. Two extension cords
2. One of the two extension cords was plugged into a surge protector connecting another surge protector to the first surge protector.

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.