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The facility failed to provide the correct building construction type per code. Findings include:

During the survey, the following was observed:

1. Per observation and interview the following are examples of areas that did not have the required one hour ceiling assembly:
a. Outside Gas Water Heater Room
b. Outside Biohazard Room
c. Outside Oxygen Storage Room
d. Outside Suction Pump Room
e. Dining Room
f. Dietary Office
g. Lab.
h. X-ray

2. The Supply Room at the Nurses' Station was observed with two unsealed penetrations in the plaster ceiling.

3. The ceiling registers in the one hour ceiling assembly were observed without dampers throughout the facility.

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 the corridor openings per code.

A) During the survey, the following was observed:
1. The door from Surgery which opens into the corridor was held in the open position by a wooden chock.
2. The door from X-Ray which opens into the corridor was held in the open position by a wooden chock.
3. The door from ULTRASound/Laboratory which opens into the corridor was held in the open position by a wooden chock.
4. The door from the Main Lobby of the hospital, which opens into the corridor located by the Nurses' Station, was held in the open position by a wooden chock.

NFPA 101, 19.3.6.3 In smoke compartments without a sprinkler system, doors in corridor walls shall be constructed to resist fire and the passage of smoke for at least twenty minutes.


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B) The following are examples of corridor doors that were observed without positive latching hardware:
1. Kitchen
2. Supply Room at the Nurses' Station

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 maintain the hazardous areas per code. Findings include:

During the survey, the following was observed:
1. The Outside Gas Water Heater Room had an approximately 3'-0" X 2'-0" unsealed penetration in the back wall.

2. The following are examples of room doors that were not 45 minute fire rated and did not have self-closing devices.
a. X-ray File Storage Room
b. Dietary Storage Room
c. Medical Records File Storage Room
d. The corridor door to Central Supply and Surgery (being used for storage)

2000 NFPA 101, 19.3.2.1 Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

2000 NFPA 101, 8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.
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A) The facility did not meet means of egress requirements. Findings include: During the survey, the Exit Discharge for the Dietary Exit was observed to have 8 inch change in elevation.

NFPA 101, 7.1.6.2 Abrupt changes in elevation of walking surfaces shall not exceed 1/4 inch.


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B) The facility failed to maintain the exit access per code. Findings include:

During the survey, the following was observed:

1. The following are examples of corridor doors that swung into the corridor and projected more than 7" into the corridor when fully opened:

a. Restroom by the Dining Room
b. Janitor's Room by the Dining Room
c. Room to the back of the autoclaves by the Nurses' Station

2. The Central Supply Room door had a hasp with a lock on it.

2000 NFPA 101, 19.2.1 Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
2000 NFPA 101, 7.2.1.4.4 During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open. Doors shall not open directly onto a stair without a landing. The landing shall have a width not less than the width of the door. (See 7.2.1.3.)

2000 NFPA 101, 7.2.1.4.3 A door shall swing in the direction of egress travel where used in an exit enclosure or where serving a high hazard contents area, unless it is a door from an individual living unit that opens directly into an exit enclosure.
2000 NFPA 101, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
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The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, the Exit Discharge lighting for the following Exits was controlled by switches. As an example see the following:

1. The Exit by Patient Room 146.

2. The Exit at the Main Entrance of the facility.

3. The Exit by Patient Room 131.

4. The Exit from Dietary.

NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.

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

During the survey, the Dietary exit was observed with a nonilluminated exit sign.

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 conduct fire drills per code. Findings include:

During the survey, per documentation and interview, no fire drill was conducted on the second shift in the fourth quarter of 2010.

2000 NFPA 101, 19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
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The facility failed to maintain the fire alarm system per code. Findings include:

During the survey, per documentation and interview, the last fire alarm annual inspection was conducted on 04/16/09.

1999 NFPA 72, 7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

1999 NFPA 72, 7-2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2.
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The facility failed to maintain the smoke detectors per code. Findings include:

During the survey, the facility could not provide documentation that a sensitivity test on the smoke detectors had been done within the last two years.

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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The facility failed to provide required maintenance for fire extinguishers. Findings include: During the survey, the Fire Extinguisher by the Nurses' Station was observed to have a blank space for December of 2010, monthly inspection was not conducted; all other months for 2010 had been signed off on the card.

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

A) The facility failed to maintain the dietary hood extinguishing system: Findings include: Based upon documentation provided during the survey, the inspection coducted by B and C Fire Safety Inc, on 5/20/2010, noted the tank was due for a hydrostatic test. On the inspection report for 12/30/2010, B and C noted that the tank was due for a hydrostatic test, last test was conducted in 1998.
Based upon interview with the Maintanance Director, the tank had not been tested.

1998 NFPA 17, 9-5 Hydrostatic testing of the extinguishment cylinder shall not exceed 12 years.


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B) The facility failed to maintain the kitchen hood automatic suppression system per code. Findings include:
During the survey, the following was observed:
1. Per documentation and interview, the facility was not conducting monthly inspections on the automatic suppression system for the kitchen hood.
2. The deep fat fryer under the kitchen hood did not have automatic suppression protection (facility stated that the deep fat fryer was not used).

1998 NFPA 17A, 5-2.1 Inspection shall be conducted on a monthly basis in accordance with the manufacturer's listed installation and maintenance manual or the 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) No obvious physical damage or condition exists that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps are intact and undamaged.
(h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.
1998 NFPA 96, 7-1.2 Cooking equipment that produces grease-laden vapors (such as, but not limited to, deep fat fryers, ranges, griddles, broilers, woks, tilting skillets, and braising pans) shall be protected by fire-extinguishing equipment.
1998 NFPA 96, 7-2.1 Fire-extinguishing equipment shall include both automatic fire-extinguishing systems as primary protection and portable fire extinguishers as secondary backup.

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

During the survey, three wheelchairs were observed obstructing the means of egress in the corridor across from room 146 during the survey.

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 provide flame resistance documentation on the draperies: Findings include:

During the survey, the facility could not provide documentation on the flame resistance of the draperies throughout the facility.

2000 NFPA 101, 10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

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

A) During the survey, two oxygen cylinders were observed to be unsecured in the Outside Storage Room.

1999 NFPA 99, 8-3.1.11.2(g) Cylinders shall be secured from mechanical shock.


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B) During the survey, the Outside Oxygen Storage Room was observed with a light switch mounted at 48".

1999 NFPA 99, 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) * Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
1. Sources of heat in storage locations shall be protected or located so that cylinders or compressed gases shall not be heated to the activation point of integral safety devices. In no case shall the temperature of the cylinders exceed 130?F (54?C). Care shall be exercised when handling cylinders that have been exposed to freezing temperatures or containers that contain cryogenic liquids to prevent injury to the skin.
2. * Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
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The facility failed to maintain the piped medical gas system per code. Findings include:

During the survey, per documentation and interview, the last inspection on the oxygen medical gas system was 08/10/2007.

1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.
(c) Maintenance programs in accordance with the manufacturers ' recommendations shall be established for the medical air compressor supply system as connected in each individual installation.

(g) A periodic testing procedure for nonflammable medical gas and related alarm systems shall be implemented.

(h) The test specified in 4-3.4.1.3(i) shall be conducted on the downstream portions of the medical gas piping system whenever a system is breached or whenever modifications are made or maintenance performed.

(i) * Periodic retesting of audible and visual alarm indicators shall be performed to determine that they are functioning properly, and records of the test shall be maintained until the next test.

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i) Sprinkler coverage was observed during the survey not adequately provided. Findings include: During the survey, the following was observed:

A) The escutcheon plate was missing on a sprinkler in the Maintenance Shop/Storage area.

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.


B) Two 6' x 6' overhangs are not provided with sprinkler coverage.

1999 NFPA 13, 5-13.8 Sprinklers shall be installed under exterior combustible roofs or canopies exceeding four feet in width, or over areas where combustibles are stored.


ii) The facility failed to provide a sprinkler system which meets code requirements. Findings include: During the survey, the following was observed:

The Fire Department Connection was placed to close to the fire main, which enters the building to the right of the fire department connection. Because of location, it obstructs the right connection of the fire department connection, in the event hose had to be connected to supply the sprinkler system, it could restrict the flow of water.

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.


C) During the survey, the facility was not able to provide a written policy concerning the Fire Alarm being out of service for 4 or more hours in a 24 hour period.

NFPA 101, 9.6.8.1 When a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

D) During the survey, the facility was not able to provide a written policy concerning the Sprinkler System being out of service for 4 or more hours in a 24 hour period.

9.7.6* Sprinkler System Shutdown.

9.7.6.1 When a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.


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E) The facility failed to maintain the following systems per code. Findings include:

During the survey, the following was observed:
1. During the survey, per documentation and interview, the last fire alarm annual inspection was conducted on 04/16/09.

1999 NFPA 72, 7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

1999 NFPA 72, 7-2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2.
2. During the survey, the facility could not provide documentation of conducting quarterly sprinkler inspections. The last tag on the riser was dated 08/26/2009.

2000 NFPA 101, 9.7.5 All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
See attached.
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A) During the survey, the generator was observed not to have met the requirements to transfer from normal to emergency power within 10 seconds. This surveyor observed the Maintenance Director conduct the transfer of the generator, at 8 seconds. The generator transferred to load, but failed to run at full capacity. After approximatley 20 seconds, the generator was surging and did not begin to run at its full potential until the Maintenance Director placed his hand on the governor rod. Based upon interview with the Maintenance Director, he advised this suveyor that the governor had been replaced recently.

NFPA 101, 7.9.2.3, and 1999 NFPA 99, 3-4.1.1.8, 3-5.3.1 and 3-6.3.1.2 Emergency generator shall start/crank and transfer from normal to emergency power within ten seconds.


B) Documentation provided for the Monthly exercise of generator under load, indicated the generator was run under load for 30 minutes only on 4/4/2010, 11/16/2010, and 12/12/2010. Based upon interview with the Maintenance Director, he had not run generator under load at any other time.

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.

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

During the survey, the following emergency battery back-up lights did not illuminate when tested:

1. In the generator shed
2. In the Main Electrical Room for the generator's transfer switch

1999 NFPA 110, 5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
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B) At the time of the survey, a generator Remote Annunciator was not observed in the facility.

NFPA 99,3-6.1.1 Generators shall conform to 3-4.1.1.

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 maintain the electrical system per code. Findings include:
A) During the survey, the following was observed:

1. Junction box was missing the cover in the Maintenance Office.

2. Junction box was missing the cover in the Pump Room.

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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B) During the survey, the Physicians' Dictating Room was observed with a receptacle that was missing a cover plate.

1999 NFPA 70, 410-3 Fixtures, lampholders, lamps, and receptacles shall have no live parts normally exposed to contact. Exposed accessible terminals in lampholders, receptacles, and switches shall not be installed in metal fixture canopies or in open bases of portable table or floor lamps.
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During the survey, the facility was not able to provide a written policy concerning the Fire Alarm being out of service for 4 or more hours in a 24 hour period.

NFPA 101, 9.6.8.1 When a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.