HospitalInspections.org

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Based on observation during the survey on 02/23/2016, the facility failed to provide the minimum construction type, Type II(111), for a three story health care occupancy building:

1. The following areas were observed with a Type II (000) construction:
a. Third Floor - in the "connecting corridor" in front of the elevators
b. First Floor - in the back corridor by rooms 129 and 130 at the two hour fire barrier
2. The following areas were observed with a Type V (000) construction:
a. Third Floor - between the elevator lobby and the two hour fire barrier for the Administration Building, including the bathrooms
b. Second Floor - between the elevator lobby and the two hour fire barrier for the Administration Building, including the bathrooms
c. First Floor - between the elevator lobby and the two hour fire barrier for the Administration Building, including the bathrooms
d. Ground Floor - between the elevator lobby and the two hour fire barrier for the Administration Building, including the bathrooms

The deficiency impacted 5 of 7 smoke compartments.
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Review of 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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Based on observation of the elevator shaft under elevator #1 on the ground floor on 02/24/2016 the facility failed to maintain one hour fire resistance for exsting veritical opening. Findings include:

The left side of the elevator shaft wall under elevator # 1 on the ground floor was observed with two unsealed pipes penetrating the left side wall of the elevator shaft.

The deficiency impacted 1 of 2 smoke walls.
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2000 NFPA 101, 19.3.1.1 Any vertical openings shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.


2000 NFPA 101, 8.2.5.1 Every floor that separates stories in a building shall be constructed as a smoke barrier to provide a basic degree of compartmentation. (See 3.3.182 for definition of Smoke Barrier.)

8.2.5.2* Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.
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Based on observation during the survey on 02/23/2016, the facility failed to mount the portable fire extinguishers at the correct height.

Second Floor at Environmental Services (EVS) a portable fire extinguisher was observed mounted approximately 5"-6" above the finished floor.

The deficiency impacted 1 of 7 smoke compartments.
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Review of 2000 NFPA 101, 19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.

Review of 2000 NFPA 101, 9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Review of 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).
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Based on observation of the designated smoking area on 02/23/2016 the facility failed to maintain the Smoking Area. Findings include:

There was no metal container with self-closing cover device (butt can) provided which ashtrays could be emptied into and an excessive amounts of cigarette butts were observed on the grounds around the designated smoking area.

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2000 NFPA 101, 19.7.4* Smoking.

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A) Based on observation on 2/23/2016, the facility failed to maintain the automatic sprinkler system. Findings include:

Escutcheon plate was observed missing on a sprinkler in the Dialysis equipment room.
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2000 NFPA 101, 39.1.5.2, For purposes of the design of an automatic sprinkler system, a business occupancy shall be classified as a light hazard occupancy in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

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.

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B) Based on observation on 2/23/2016, the facility failed to maintain the integrity of sprinkler coverage. Findings include:

1. Ceiling tile missing in Beauty Shop storage room.
2. Ceiling tile missing in Dialysis equipment room.
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2000 NFPA 101, 39.1.5.2, For purposes of the design of an automatic sprinkler system, a business occupancy shall be classified as a light hazard occupancy in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

1998 NFPA 13, 5-5.4.1* Distance Below Ceilings. The distances between the sprinkler deflector and the ceiling above shall be selected based on the type of sprinkler and the type of construction. 1998 NFPA 13, 5-5.4.2 Deflector Orientation. Deflectors of sprinklers shall be aligned parallel to ceilings, roofs, or the incline of stairs.

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C) Based on observation on 2/23/2016, the facility failed to maintain the electrical system. Findings include:

Two junction boxes were missing the covers, above the ceiling at the entrance to the Engineering Office.
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NFPA 2000 Edition, 21.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.

NFPA 2000 Edition, 9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code.

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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D) Based on observation on 2/23/2016, the facility failed to maintain a fire barrier for the separation between additions. Findings include:

The fire barrier located at the entrance to hallway for Patient Room 123 thru 130, did not have the sheet rock extended to the deck, this was observed on both sides of the barrier.
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NFPA 2000 Edition, 21.1.1.4.1 Additions shall be separated from any existing structure not conforming to the provisions within Chapter 21 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. (See 4.6.3 and 4.6.6.)

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36148

E) Based on observation of the post indicator valve on 02/23/2016 the facility failed to maintain the post indicator valve being provided with appropriate identification. Findings include:

The post indicator valve located outside behind the administration building near the smoking area was observed with a missing sight glass and was not provided with appropriate identification.
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2000 NFPA 101, 21.7.6 Maintenance and Testing. (See 4.6.12.)

2000 NFPA 101, 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. e 4.6.12.)

1998 NFPA 25, 7-3.7.1 Gate valves, post indicator valves, wall indicator valves, or other control valves for water supply systems shall be inspected to verify that they are in the open position and properly sealed, locked, or supervised. (See Chapter 9 for inspection and maintenance requirements.)

1998 NFPA 25,9-3.3.2* The valve inspection shall verify that the valves are in the following condition: (a) In the normal open or closed position (b) * Properly sealed, locked, or supervised (c) Accessible (d) Provided with appropriate wrenches (e) Free from external leaks (f) Provided with appropriate identification


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Based on observation on 02/23/2016 the facility failed to maintain the electrical wiring and equipment in accordance with the National Electrical Code (NFPA 70). Findings include:

In the boiler room the electrical panel box (mp-crp-mp-crii) was observed with an open space.

The deficiency impacted 1 of 2 smoke compartments.
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Review of the 2786R - Electrical wiring and equipment shall be in accordance with National Electrical Code (NFPA 70).

2000 NFPA 101,9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

1999 NFPA 70,Chapter 3 Article 373-4. Unused Openings. Unused openings in enclosures within the scope of this article shall be effectively closed to afford protection substantially equivalent to that of the enclosures within the scope of this article. Where metal plugs or plates are used with nonmetallic cabinets or cutout boxes, they shall be recessed at least ¼ in. (6.35 mm) from the outer surface.
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