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The facility failed to maintain the doors protecting corridor openings per code. Findings include:

During the survey, the following is an example of what was observed:
The Nurses' Station Breakroom corridor door was not positive latching (had a roller latch device)

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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.
CMS - 2786R Fire Safety Survey Report 2000 Code - Healthcare Roller latches are prohibited by CMS regulations in all health care facilities.

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The facility failed to maintain the horizontal exit (fire doors) per code. Findings include:

During the survey, the following is an example of what was observed:
The fire doors at Mechanical Room 3 failed to latch when the fire alarm was activated

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1999 NFPA 80, 3-4.1* Closing Devices for Swinging Tin Clad and Sheet Metal Fire Doors.
Swinging tin clad and sheet metal fire doors shall be equipped with self-closing or automatic-closing devices to ensure that they are closed and latched at the time of fire. Other arrangements acceptable to the authority having jurisdiction shall be permitted.
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The facility failed to maintain the smoke barriers per code. Findings include:

During the survey, the following is are examples of what was observed:
1. The smoke barrier at Radiology - at the smoke doors:
a. Was not sealed at the corrugated roof deck
b. Had layers of sheetrock that were not sealed
2. The smoke barrier in Mechanical Room 4 had an unsealed pipe
3. The smoke barrier at the smoke doors at Mechanical Room 4 was not sealed at the corrugated roof deck

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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, 8.2.4.4.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows:
(1) The space between the penetrating item and the smoke partition shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
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 partition, the sleeve shall be solidly set in the smoke partition, 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 limiting the transfer of smoke.b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke partitions.
b. It shall be made by an approved device that is designed for the specific purpose.
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The facility failed to maintain the hazardous areas per code. Findings include:

During the survey, the following are examples of what was observed:
The following rooms were over 50 sq. ft. with combustibles and the doors did not have self-closing devices:
1. Housekeeping (Linen Storage) Room
2. Copier Room by Accounts Payable
3. EMS Supply Closet in Lounge
4. EMS Supply Room on the corridor
5. Medical Records storage Room - the door separating the Receptionist's Office from this space

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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 the exit access per code. Findings include:

During the survey, the following are examples of what was observed:
1. Padlocks were observed either in use or verified that the facility uses them at the following locations:
a. Kitchen walkin cooler
b. Kitchen walkin freezer
c. EMS supply Closet in Lounge
2. The Janitor's Closet next to room 214, when fully opened projected more than 7" into the corridor.

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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, 7.2.1.4.4 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.)
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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:
The facility failed to conduct a fire drill for the third shift for the third quarter of 2012.

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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 maintain the fire alarm system per code. Findings include:

During the survey, the following are examples of what was observed:
1. The fire alarm system at the facility did not indicate communication trouble visually or audibly.
2. While testing the fire alarm system, the remote annunciator for the fire alarm (F.A.) system was observed giving false information and locations:
a. When the smoke detector in the OR was activated the F.A. system remote annunciator indicated "special message"
b. When the Dietary Exit pull station was activated the F.A. system remote annunciator indicated "heat detector"
A fire alarm company representative came out and was unable to fix the problem. The facility told him to go ahead and order a new F.A. system remote annunciator.
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2000 NFPA 101, 19.3.4.1 Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.
1999 NFPA 72, 3-8.4.4.2.1 Relays or modules providing transmission of trouble signals to a supervising station shall be arranged to provide fail-safe operation.

2000 NFPA 101, 9.6.1.6 Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.

1999 NFPA 72, Section 1-5.4.6, 5-5.3.2.1.5, and 5-5.3.2.1.6.2. Phone line communication failure shall be indicated at the facility.

2000 NFPA 101, 9.6.6 Operator controls, alarm indicators, and manual communications capability shall be installed in a control center at a convenient location acceptable to the authority having jurisdiction.
2000 NFPA 101, 9.6.7.1 Where alarm annunciation is required by another section of this Code, it shall comply with 9.6.7.2 through 9.6.7.7.
2000 NFPA 101, 9.6.7.2 Alarm annunciation at the control center shall be by means of audible and visible indicators.
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The facility failed to maintain the smoke detectors per code. Findings include:

During the survey, the following is an example of what was observed:
The facility failed to provide documentation of a sensitivity test for the smoke detectors conducted within the last two years.

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1999 NFPA 72, 7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter.

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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 following comments were on all reports as far back as the report dated 04/10/2012:
a. "The main drain for riser #2 needs to be replaced"
b. "Sprinkler head in receptionist's office is in the wall"
c. "The main control valve #1 does not have any type of supervision"
2. The outside Biohazard Room had an approximately 2' x 2' hole cut in the sheetrock ceiling

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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.
2000 NFPA 101, 9.7.2.1 Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.
1999 NFPA 13, 5-8.4.2 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs.
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The facility failed to prohibit portable space heating devices per code. Findings include:

During the survey, the following is an example of what was observed:
A portable space heating device was observed in the Doctors' Lounge, it was not plugged in at the time of observation.
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2000 NFPA 101, 19.7.8 Portable space-heating devices shall be prohibited in all health care occupancies.
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The facility failed to maintain the medical gas storage per code. Findings include:

During the survey, the following are examples of what was observed:
1. Several large and small oxygen cylinders were observed unsecured in the EMS Oxygen Supply Closet
2. One unsecured oxygen cylinder was observed in the unused Xray Room
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1999 NFPA 99, 4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers - Level 1.
(a) * Handling of Gases. Administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility.
(b) Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed:
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
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The facility failed to maintain the following systems per code. Findings include:

During the survey, the following are examples of what was observed:
1. The two battery lights in the Generator Room did not illuminate when tested
2. The generator remote annunciator did not give an audible or a visual trouble when the generator transfer switch was taken out of the automatic transfer position

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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.
2000 NFPA 101, 19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
2000 NFPA 101, 9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.
1999 NFPA 110, 3-5.5.1 A control panel shall be provided and shall contain the following:
(a) Automatic remote start capability
(b) " Run-off-auto " switch
(c) Shutdowns [see 3-5.5.2(c)]
(d) Alarms [see 3-5.5.2(d)]
(e) Controls [see 3-5.5.2(e)]
1999 NFPA 110, 3-5.5.2 An automatic control and safety panel shall be a part of the EPS and shall contain the following equipment or possess the following characteristics, or both:
(a) Cranking control equipment to provide the complete cranking cycle described in 3-5.4.2 and Table 3-5.4.2.
(b) A panel-mounted control switch(es) marked " run-off-automatic " to perform the following functions:
1. Run: Manually initiate, start, and run prime mover
2. Off: Stop prime mover or reset safeties, or both
3. Automatic: Allow prime mover to start by closing a remote contact and stop by opening the remote contact
(c) Controls to shut down and lock out the prime mover under the following conditions: failing to start after specified cranking time, overspeed, low lubricating-oil pressure, high engine temperature, or operation of remote manual stop station. An automatic engine shutdown device for high lubricating-oil temperature shall not be required. (See 3-5.5.6.)
(d) Battery-powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2(d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).
(e) Controls to shut down the prime mover upon removal of the initiating signal or manual emergency shutdown.
(f) The ac instruments listed in 3-5.9.7. Where the control panel is mounted on the energy converter, it shall be mounted by means of antivibration shock mounts, if required, to maximize reliability.
Table 3-5.5.2(d) Safety Indications and Shutdowns
Level 1 Level 2
Indicator Function (at Battery Voltage) C.V. S R.A. C.V. S R.A.
(a) Overcrank X X X X X O
(b) Low water temp. <70?F (21?C) X X X O
(c) High engine temperature prealarm X X O
(d) High engine temperature X X X X X O
(e) Low lube oil pressure prealarm X X O
(f) Low lube oil pressure X X X X X O
(g) Overspeed X X X X X O
(h) Low coolant level X O X X O X
(i) EPS supplying load X O
(j) Control switch not in auto. position X X O
(k) High battery voltage X O
(l) Low voltage in battery X O
(m) Battery charger ac failure X O
(n) Lamp test X X
(o) Contacts for local and remote common alarm X X X X
(p) Audible alarm silencing switch X O
(q) Low starting air pressure X O
(r) Low starting hydraulic pressure X O
(s) Air shutdown damper when used X X X X X O
(t) Remote emergency stop X X
C.V.: Control panel-mounted visual indication
R.A.: Remote audible
S: Shutdown of EPS
X: Required
O: Optional
Notes:
1. Item (o) shall be provided, but a separate remote audible signal shall not be required when the regular work site in 3-5.6.1 is staffed 24 hours a day.
2. Item (b) is not applicable for combustion turbines.
3. Item (q) or (r) applies only where applicable as a starting method.
4. Item (i): EPS ac ammeter shall be permitted for this function.
5. All required C.V. functions shall be annunciated by a remote, common visual indicator. All required functions indicated in the R.A. column also shall be annunciated by a remote, common audible alarm [see 3-5.5.2(d)].
6. Item (h) on gaseous systems shall require a low gas pressure alarm.