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The Nursing Station on the Second Floor has wood, the facility ot able to provide documentation of flame spread.


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The facility failed to maintain the interior finish for corridors/exitways per code. Findings include:

During the survey, the following is an example of what was observed:
The outside of the Gift Shop in the Lobby is wood. The facility failed to provide documentation of the flame spread rating.

2000 NFPA 101, 18.3.3.2 Interior Wall and Ceiling Finish.
Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted throughout if Class A or Class B. The provisions of 10.2.8.1 shall not apply.
Exception No. 1: Walls and ceilings shall be permitted to have Class A, Class B, or Class C interior finish in individual rooms having a capacity not exceeding four persons.
Exception No. 2: Corridor wall finish not exceeding 4 ft (1.2 m) in height that is restricted to the lower half of the wall shall be permitted to be Class A, Class B, or Class C.

2000 NFPA 101, 19.3.3.1 Interior finish shall be in accordance with Section 10.2.
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The facility failed to provide corridor walls that would resist the passage of smoke. Findings include: During the survey, the following are examples of what was observed:


The Registration office on the Second Floor outpatient area had two glass sliding windows. This area was not equiped with a smoke detector.


NFPA 101, 19.3.6.2 Corridor walls shall form a barrier to limit the transfer of smoke.

The facility failed to provide corridor doors that would close and resist the passage of smoke. Findings include: During the survey, the following are examples of what was observed:

1. Patient Room 212 door failed to positive latch.


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2. The Ultrasound Room corridor door would not positive latch.
Second Floor
3. Soiled Utility Room did not have a corridor door

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.

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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:

1. Unsealed penetrations around a group of wiring, blue in color, in the Smoke barrier, by Patient Room 222.

2. Unsealed penetrations around a group of wiring, and at the end of two sleeve's, in the Smoke Barrier at the Senior Care Unit.

3. Unsealed penetrations around conduit, and at the end of a sleeve, in the Smoke Barrier at the Surgery Suite.


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4. The smoke barrier at the "EMS Closet" had an unsealed penetration of a flex conduit.

5. The smoke barrier at the Pharmacy had:
a. An unsealed penetration of a flex conduit with blue and green wires, to the right of the duct , this flex conduit was not sealed at the end
b. To the left of the duct - conduit with tan and grey wires was not sealed at the end



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:


1. Patient Room 214 has been converted to a storage room, door not provided with a self-closing device.

2. Patient Room 215 has been converted to a storage room, door not provided with a self-closing device.

3. Cardboard storage room door blocked open by a large bag of trash.

4. Second Floor West Mechanical Room had unsealed penetrations around conduit in the wall.


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5. The Boiler Room had the following:
a. An unsealed ceiling penetration near the corridor door
b. The wall separarting the hospital had an unsealed penetration of a copper pipe and a white pipe

6. Supply Room - over 50 sq. ft. with combustibles - corridor door was not positive latching

7. X-ray File Room - over 50 sq. ft. with combustibles - door not self-closing

8. Respitory Therapy Office being used as a storage room - over 50 sq. ft. with combustibles - the corridor door did not have a self-closing device
Second Floor


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.

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The facility failed to maintain stairways with at least 1 hour fire resistance rating. During the survey, the following are examples of what was observed:


Unsealed penetration Second Floor Stairwell, at the top right side. This stairwell is located in the Surgery Suite.


NFPA 101, 8.2.5.2, 19.3.1.1 stairwell provide a 1 hour fire resistance rating.

The facility failed to provide a reliable means of egress to the public way. Observed during the survey, the following findings include: During the survey, the following are examples of what was observed:


1. The East Stairwell exit discharge failed to provide an all weather surface to the public way.

2. The West Electrical Closet on the Second Floor door, when fully opened projected more than 7" into the corridor.
3. The East Electrical Closet on the Second Floor door, when fully opened projected more than 7" into the corridor.


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4. In the E.D. Suite the following corridor doors when fully opened projected more than 7" into the corridor:
a. Both Unisex Bathrooms
b. Both Restrooms at the Waiting Room

5. The Electrical Room by the Radiology Suite the corridor door when fully opened projected more than 7" into the corridor

Second Floor
6. Maglocks were observed on The Surgery Suite automatic control doors. During the survey approximately 12:45 pm, an employee was oberseved at the doors on the non egress side of the doors. The doors would not open when the employee was in the area of the sensor preventing egress from the surgery suite.
The power to the maglocks was removed before the surveyors left the facility.
7. The manual release device for the doors was not located within 5 feet of the doors and did not realease the magnetic locking device for at least 30 seconds.

7 The Electrical Closet in the Surgery Suite when opened blocks the exit door.

8. The bottom part of the stairs in the Surgery Suite had only 38" from handrail to handrail.







NFPA 101, A.7.1.10.1 *A proper means of egress allows unobstructed travel at all times. Any type of barrier including, but not limited to, the accumulations of snow and ice in those climates subject to such accumulations is an impediment to free movement in the means of egress.

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, 7.2.1.5.1 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.

2000 NFPA 101, 7.2.1.6.2 Access-Controlled Egress Doors. Where permitted in Chapters 11 through 42, doors in the means of egress shall be permitted to be equipped with an approved entrance and egress access control system, provided that the following criteria are met. (a) A sensor shall be provided on the egress side and arranged to detect an occupant approaching the doors, and the doors shall be arranged to unlock in the direction of egress upon detection of an approaching occupant or loss of power to the sensor.(b) Loss of power to the part of the access control system that locks the doors shall automatically unlock the doors in the direction of egress. (c) The doors shall be arranged to unlock in the direction of egress from a manual release device located 40 in. to 48 in. (102 cm to 122 cm) vertically above the floor and within 5 ft (1.5 m) of the secured doors. The manual release device shall be readily accessible and clearly identified by a sign that reads as follows:
PUSH TO EXIT
When operated, the manual release device shall result in direct interruption of power to the lock - independent of the access control system electronics - and the doors shall remain unlocked for not less than 30 seconds.
(d) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the doors in the direction of egress, and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.
(e) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.

7.2.2.2.1 Standard Stairs.
(b) * Existing stairs shall be permitted to remain in use, provided that they meet the requirements for existing stairs shown in Table 7.2.2.2.1(b). Where approved by the authority having jurisdiction, existing stairs shall be permitted to be rebuilt in accordance with the dimensional criteria of Table 7.2.2.2.1(b) and in accordance with other Code requirements in 7.2.2 for stairs.
Table 7.2.2.2.1(b) Existing Stairs
Feature Class A Class B
Minimum width clear of all obstructions, except projections not more than 31/2 in.
(8.9 cm) at or below handrail height on each side 44 in. (112 cm) 44 in. (112 cm)
36 in. (91 cm) where total occupant load of all stories served by stairways is fewer than 50

The facility failed to provide a written plan of evacuation per code. Findings include:

During the survey, the following is an example of what was observed:
The verbage "evacuate the effected smoke compartment to an uneffected smoke compartment" was not in the written plan of evacuation.





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 is an example of what was observed:
Per documentation and interview with the staff, not all employees are signing and or participating in the fire drills.




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 provide a fire alarm system that provided effective warning of a fire in aall parts of the builidng. Findings include: During the survey, the following are examples of what was observed:


During the testing of the fire alarm system, this surveyor observed no audible/visual device in OR # 1 and 2. This surveyor went in OR while the alarm was sounding, and was unable to hear the alarm with the door closed.

19.3.4.3.1 Occupant Notification.
Occupant notification shall be accomplished automatically in accordance with 9.6.3.
Exception No. 1*: In lieu of audible alarm signals, visible alarm-indicating appliances shall be permitted to be used in critical care areas.

9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.

9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.

a) Sprinkler coverage was observed during the survey not adequately provided. Findings include:

1. Sprinkler deflector covered with plastic in the trash only storage room.

2. Escutcheon plate missing on a sprinkler in the closet Patient Room 215.

3. Escutcheon plate missing on a sprinkler in the cooler.

4. A 12' x 18' canopy which is noncombustible was observed to have 10 trash containers stored under canopy.

5. Shelfing in the dietary storage room is approximatley 2 inches below the sprinkler head. Also this surveyor observed items stored on top shelf.


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.

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.

The clearance between the deflector and the top of storage shall be
18 inches or greater. 1999 NFPA 13,5-5.5.2.1 and 5-6.5.2.1.


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B) During the survey, the following are examples of what was observed:
The following rooms did not have sprinkler coverage:
1. The Data Room in the Lab
Second Floor
2. The Electrical Closet by the Surgery Elevator and Surgery Waiting Room

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 Type Stories
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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1. The Fire Department connection was not provided with the FDC signage.

2. Documentation for the quarterly inspection of the sprinkler systems, were conducted on 7/28/2010, 11/22/2010, 2/28/2011, 7/12/2011. A quarterly inspection should have been conducted in June 2011.

NFPA 101, 4.6.12, and NFPA 25, 2-2 and Table 2-1 Requires an inspection every quarter (three months).

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 conition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.








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

During the survey, the following are examples of what was observed:
1. The Computer Lab - missing several ceiling tiles
2. The following rooms were missing escutcheon plates:
a. X-ray Prep. Room
b. X-ray Room 2 - the Restroom and the Storage Room
c. The corridor in front of the Lab
Second Floor
d. Endoscopy Room
3. The Volunteer Services Closet - had obstructions closer than 18" to the sprinkler head




1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.
1999 NFPA 13, 3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.
1999 NFPA 13, 5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
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The facility failed to maintain the fire extinguishers per code. Findings include:


a) The K-Extinguisher in the Kitchen was mounted approximately 6 foot from the top of the extinguisher to the floor.


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b) During the survey, the following are examples of what was observed:
1. The fire extinguisher in the Lab was mounted over 5'-0"
2. The fire extinguisher between the two radiology rooms was obstructed and mounted over 5'-0"
3. The fire extinguisher in the Old Bussiness Office last monthly documented inspection was May 2011
4. The fire extinguisher in Quality Management last monthly documented inspection was June 2011






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

1998 NFPA 10, 4-3.2 Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) * Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place
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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 are examples of what was observed:


Metal self-closing container for disposing of cigarette butts was not provided at the designated smoking area.




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.

The facility failed to provide a readily accessible means of egress pathway at all times. Findings include: During the survey, the following are examples of what was observed:

A Med Cart, two trash cans, and a cleaning cart was stored in the corridor, on the Second Floor from 9:00am-10:30am.




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.

Corridors must be maintained free of all furniture and other items. Items are considered stored in the corridor if they are not both used and moved at least once every half hour. Transmittal #99-94.

The facility failed to provide proper storage of oxygen cylinders. Findings include: During the survey, the following are examples of what was observed:


Ten unsecured oxygen cylinders in the empty cylinder storage room.




1999 NFPA 99, 4-3.1.1.1 and 4-5.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

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


1.Cover was missing on a junction box, also items were stored in front of the electrical panel, in the electrical closet by Patient Room 221.

2. Cover missing on the junction box of the fan motor in the cooler.


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3. The Doctors' Lounge in the E.D. Suite had an extension cord in use

4. The Preaction Sprinkler Closet had an electrical junction box with the cover not attached completely

5. The Emergency Wash Station in the Lab had an electrical switch missing the cover plate

Second Floor
6. Missing cover plate for the electrical switch at the stairs in the Surgery Suite



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

1999 NFPA 70, 370-28. Pull and Junction Boxes
Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d).
(c) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.

1999 NFPA 70, 370-25. Covers and Canopies In completed installations, each box shall have a cover, faceplate, or fixture canopy.
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The facility failed to provide a fire watch per code. Findings include:

During the survey, the following is an example of what was observed:
Per documentation provided by the facility the fire watch plan did not include times to do the walk thru of the facility - every 15 - 30 minutes.



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

During the survey, the following is an example of what was observed:
Per documentation provided by the facility the fire watch plan did not include times to do the walk thru of the facility - every 15 - 30 minutes.

2000 NFPA 101, 9.6.1.8 Where 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.