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The facility failed to maintain the two fire barrier per code. Findings include:

During the survey, the following is an example of what was observed:
The two hour floor-ceiling assembly fire barrier in the maintenance office/shop in the partial basement had unsealed penetrations.

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2000 NFPA 101, 8.2.3.1.1 Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2.
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The facility failed to maintain the corridor openings per code. Findings include:

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

1. Patient Room 306 door failed to positive latch.


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2. Corridor doors through out the First Floor of this building had unsealed penetrations
3. The following corridor doors were not positive latching:
a. E.R. Suite corridor doors
b. E.R. Copier Room
c. X-ray Office
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2000 NFPA 101, 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
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 separation of hazardous areas. Findings include: During the survey, the following is an example of what was observed:

The self-closing device was not provided for the door which separates the kitchen from the Dining Room. The closing device had been removed hardware was still attached to the door.
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NFPA 101, 19.3.2.1 or 18.3.2.1 Hazardous areas were observed without the required one-hour fire resistance rating for hazardous rooms which do not have sprinkler coverage.
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The facility failed to provide readily accessible exits at all times. Findings include: During the survey, the following is an example of what was observed:

The Exit failed to open when normal pressure was applied, Exit is located by the Kitchen partial basement.

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NFPA 101, 7.2.1.4.5 The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf to release the latch, 30 lbf to set the door in motion, and 15 lbf to open the door to the minimum required width.

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The facility failed to provide fire barriers that limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. Findings include: During the survey, the following is an example of what was observed:

The door failed to latch in the fire wall located by the Kitchen partial basement.

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NFPA 101, 19.2.2.5 and 7.2.4.3 Openings in fire barriers shall be constructed to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.

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The facility failed to provide continuous lighting for means of egress. Findings include: During the survey, the following is an example of what was observed:


A single bulb light fixture was observed at the exit discharge for the Exit at the Loading dock.
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NFPA 101, 19.2.8 and 7.8.1.2 Illumination of means of egress shall be continuous.

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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 interview and documentation provided by the facility, the facility was not conducting fire drills at unexpected times. The following is an example of when drills were conducted.
Second Shift
06/11/2012 - 5:55am
03/29/2012 - 5:58am
12/23/2012 - 6:00am
09/27/2012 - 6:00am

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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 perform sensitivity testing of the smoke detectors. Findings include: During the survey, the following is an example of what was observed:

Documentation provided by the facility did not indicate sensitivity testing of the smoke detectors. Detector sensitivity shall be checked with one year after installation and every alternate year thereafter per 72, 7-3.2.1. (Up to 5 years permitted under certain circumstances. See 7-3.2.1).

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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. A 6' x 8' overhang combustible materials, at the main entrance of the facility was not provided with sprinkler coverage.

2. A 5' x 5' overhang combustible materials, at the Exit Discharge for the Exit by Isolation Room 306, was not provided with sprinkler coverage.

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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.

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1) The facility failed to comply with the required maintenance of the facility sprinkler system. During the survey, the following is an examples of what was observed:

The fire department connection was not provided with a identification sign.

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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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2) The facility failed to maintain the automatic sprinkler heads per code. Findings include:

During the survey, the following are examples of what was observed:
The following closets' clearance between the deflector and the top of storage was closer than 18":
1. Administrator's Office
2. Lab.

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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 provide metal self-closing containers for disposing of cigarette butts and ashes from ashtrays. Findings include: During the survey, the following is an example of what was observed:

A metal self-closing container for disposing of cigarette butts, was not provided in the designated smoking area.
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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.

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

During the survey, the following is an example of what was observed:
The facility failed to provide documentation of servicing the kitchen hood's automatic suppression system every six months

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1998 NFPA 17A, 5-3.1 A trained person who has undergone the instructions necessary to perform the maintenance and recharge service reliably and has the applicable manufacturer ' s listed installation and maintenance manual and service bulletins shall service the wet chemical fire extinguishing system 6 months apart as outlined in 5-3.1.1.
1998 NFPA 17A, 5-3.1.1 At least semiannually, maintenance shall be conducted in accordance with the manufacturer ' s listed installation and maintenance manual. As a minimum, such maintenance shall include the following:
(a) A check to see that the hazard has not changed
(b) An examination of all detectors, the expellant gas container(s), the agent container(s), releasing devices, piping, hose assemblies, nozzles, signals, all auxiliary equipment, and the liquid level of all nonpressurized wet chemical containers
(c) * Verification that the agent distribution piping is not obstructed
(d) Where semiannual maintenance of any wet chemical containers or system components reveals conditions such as, but not limited to, corrosion or pitting in excess of the manufacturer ' s limits; structural damage or fire damage; or repairs by soldering, welding, or brazing; the affected part(s) shall be replaced or hydrostatically tested in accordance with the recommendations of the manufacturer or the listing agency. The hydrostatic testing of wet chemical containers shall follow the applicable procedures outlined in Section 5-5.

(e) All wet chemical systems shall be tested, which shall include the operation of the detection system signals and releasing devices, including manual stations and other associated equipment. A discharge of the wet chemical normally is not part of this test.
(f) Where the maintenance of the system(s) reveals defective parts that could cause an impairment or failure of proper operation of the system(s), the affected parts shall be replaced or repaired in accordance with the manufacturers ' recommendations.
(g) The maintenance report, with recommendations, if any, shall be filed with the owner or with the designated party responsible for the system.
(h) * Each wet chemical system shall have a tag or label securely attached, indicating the month and year the maintenance is performed and identifying the person performing the service. Only the current tag or label shall remain in place.

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

The corridor in the partial basement had beds, trash cans, hand trucks, and two sofa's stored in the corridor from the time the survey began until this surveyor exited the facility.

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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.

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The facility failed to maintain the piped in med gas systems per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide documentation of an inspection on the piped in oxygen and vacuum lines

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1999 NFPA 99, 4-3.5.2.3 Patient Gas Systems - Level 1.
(a) * Piping systems shall not be used for the distribution of flammable anesthetic gases.
(b) Nonflammable medical gas systems used to supply gases for respiratory therapy shall be installed in accordance with 4-3.1 of this chapter.
(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.
(d) * The responsible authority of the facility shall establish procedures to ensure that all signal warnings are promptly evaluated and that all necessary measures are taken to reestablish the proper functions of the medical gas system.
(e) Piping systems for gases shall not be used as a grounding electrode.
(f) The facility shall have the capability and organization to implement a plan to cope with a complete loss of any medical gas system.
(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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The facility failed to maintain anesthetizing locations per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide a battery back-up light in the OR Room

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1999 NFPA 99, 3-3.2.1.2 All Patient Care Areas.
5. Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).
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The facility failed to provide proper signage for the above ground diesel tank. Findings include: During the survey, the following are examples of what was observed:

1. The above ground diesel tank did not have signage to identify hazard.

2. The above ground diesel tank was not provide with a no smoking sign.

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NFPA 30 2-9.3, Unsupervised aboveground storage tanks shall be secured and marked in such a manner as to identify the fire hazards of the tank and its contents to the general public. The area in which the tank is located shall be protected from tampering or trespassing, where necessary.

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The facility failed to provide a remote annunciator for the generator. Findings include:

During the survey, base on observation the generator was not provided with a remote annunciator.

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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 provide receptacles for appliances. Findings include: During the survey, the following are examples of what was observed:

1. Junction box was missing the cover in the Southside Mechanical Room.

2. A overcurrent protection device was plugged into a another overcurrent protection device, in Respitory Therapy.

3. Extension cord was in use for fax machine in the Physical Therapy Office.


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4. Ultrasound Room 301 - had an extension cord for the treadmill going through the ceiling

5. E.R. Doctors' Room - had a refrigerator and a microwave plugged into a surge protector

6. E.R. Pharmacy - had two homemade extension cords in use, one had a refrigerator plugged into it

7. Lab. - had a microwave and a refrigerator plugged into a three way adapter that was plugged into an extension cord

8. Doctors' Lounge - had an extension cord in use

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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.

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The facility failed to provide a fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide a fire watch policy

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2000 NFPA 101, 9.7.6.1 Where 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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The facility failed to provide a fire watch policy per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide a fire watch policy

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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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