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

During the survey, the facility was observed with a partial sprinkler system and a non conforming construction type for a facility with partial sprinkler system. (Separation is not maintained between the construction types.)
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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 provide an interior finish for rooms per code. Findings include:

During the survey, the following is an example of what was observed:
First Floor
The facility failed to provide flame spread documentation for the full height wood paneling in the Chapel

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2000 NFPA 101, 19.3.3.2 Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted as follows: (1) Existing materials - Class A or Class B
Exception: In rooms protected by an approved, supervised automatic sprinkler system, existing Class C interior finish shall be permitted to be continued to be used on walls and ceilings within rooms separated from the exit access corridors in accordance with 19.3.6.
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The facility failed to maintain the doors protecting the corridor openings per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
The following corridor doors were observed without positive latching hardware:
1. Behavioral Psych. Unit
2. Lab. Waiting Room (across from the Lab.)

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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.
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The facility failed to maintain the smoke barriers per code. Findings include:

During the survey, the following are examples of what was observed:
1. The smoke barrier - left wall in front of the dumbwaiter:
a. Two unsealed conduit ends
b. One electrical junction box - no cover plate
2. The smoke barrier in the Geri Psych Intake Room:
a. Unsealed penetration of HVAC duct and copper pipe
b. Unsealed penetration
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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 provide a fire alarm system per code. Findings include:

During the survey, the following are examples of what was observed:
First Floor
1. No fire alarm device was observed in Nuclear Med. smoke compartment corridor and the fire alarm could not be heard in rooms of this smoke compartment
2. The PIV in front of the building was observed without having electronically supervision

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2000 NFPA 101, 9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
2000 NFPA 101, 9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
2000 NFPA 101, 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.
2000 NFPA 101, 9.7.2.1* Supervisory Signals. 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.
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The facility failed to maintain the fire alarm system per code. Findings include:

During the survey, the following is an example of what was observed:
Second Floor
The set of double cross corridor doors at ICU that have magnetic locks failed to release under loss of primary power to the fire alarm
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1999 NFPA 72, 3-9.7.1 Any device or system intended to actuate the locking or unlocking of exits shall be connected to the fire alarm system serving the protected premises.
1999 NFPA 72, 3-9.7.3 All exits connected in accordance with 3-9.7.1 shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply shall not be utilized to maintain these doors in the locked condition.
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The facility failed to maintain the automatic sprinkler system per code. Findings include:

During the survey, the following is an example of what was observed:
A combustible canopy over ten feet in width without sprinkler protection was observed at the ER designated smoking area

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1999 NFPA 13, 5-13.8.1 Sprinklers shall be installed under exterior roofs or canopies exceeding 4 ft (1.2 m) in width. Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction.
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The facility failed to maintain the designated smoking areas per code. Findings include:

During the survey, the following are examples of what was observed:
The following designated smoking areas:
1. ER
2. West Wing
3. Geri Psych
were observed without the following provisions:
a. Ashtray of noncombustible material
b. Metal cotainer with a self-closing cover device

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2000 NFPA 101, 19.7.4 Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (2) Smoking by patients classified as not responsible shall be prohibited. Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision. (3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
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The facility failed to maintain the Line Isolation Power System per code. Findings include:

During the survey, the following are examples of what was observed:
1. Per interview the facility was not performing monthly testing on the Line Isolation Monitor
2. Per observation OR 1 and OR 2 did not have audible alarms for the Line Isolation Monitor

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1999 NFPA 99, 3-3.2.2.3 Line Isolation Monitor. (a) * In addition to the usual control and protective devices, each isolated power system shall be provided with an approved continually operating line isolation monitor that indicates possible leakage or fault currents from either isolated conductor to ground. (b) The monitor shall be designed such that a green signal lamp, conspicuously visible to persons in the anesthetizing location, remains lighted when the system is adequately isolated from ground; and an adjacent red signal lamp and an audible warning signal (remote if desired) shall be energized when the total hazard current (consisting of possible resistive and capacitive leakage currents) from either isolated conductor to ground reaches a threshold value of 5.0 mA under normal line voltage conditions. The line isolation monitor shall not alarm for a fault hazard current of less than 3.7 mA. (c) The line isolation monitor shall have sufficient internal impedance such that, when properly connected to the isolated system, the maximum internal current that will flow through the line isolation monitor, when any point of the isolated system is grounded, shall be 1 mA. Exception:* The line isolation monitor is permitted to be of the low-impedance type such that the current through the line isolation monitor, when any point of the isolated system is grounded, will not exceed twice the alarm threshold value for a period not exceeding 5 msec. (d) * An ammeter connected to indicate the total hazard current of the system (contribution of the fault hazard current plus monitor hazard current) shall be mounted in a plainly visible place on the line isolation monitor with the " alarm on " (total hazard current = 5.0 mA) zone at approximately the center of the scale. It is desirable to locate the ammeter such that it is conspicuously visible to persons in the anesthetizing location. (e) Means shall be provided for shutting off the audible alarm while leaving the red warning lamp activated. When the fault is corrected and the green signal lamp is reactivated, the audible alarm silencing circuit shall reset automatically, or an audible or distinctive visual signal shall indicate that the audible alarm is silenced. (f) A reliable test switch shall be mounted on the line isolation monitor to test its capability to operate (i.e., cause the alarms to operate and the meter to indicate in the " alarm on " zone). This switch shall transfer the grounding connection of the line isolation monitor from the reference grounding point to a test impedance arrangement connected across the isolated line; the test impedance(s) shall be of the appropriate magnitude to produce a meter reading corresponding to the rated total hazard current at the nominal line voltage, or to a lesser alarm hazard current if the line isolation monitor is so rated. The operation of this switch shall break the grounding connection of the line isolation monitor to the reference grounding point before transferring this grounding connector to the test impedance(s), so that making this test will not add to the hazard of a system in actual use, nor will the test include the effect of the line to ground stray impedance of the system. The test switch shall be of a self-restoring type. (g) The line isolation monitor shall not generate energy of sufficient amplitude and/or frequency, as measured by a physiological monitor with a gain of at least 104 with a source impedance of 1000 ohms connected to the balanced differential input of the monitor, to create interference or artifact on human physiological signals. The output voltage from the amplifier shall not exceed 30 mV when the gain is 104. The 1000 ohms impedance shall be connected to the ends of typical unshielded electrode leads (which are a normal part of the cable assembly furnished with physiological monitors). A 60-Hz notch filter shall be used to reduce ambient interference (as is typical in physiological monitor design).
1999 NFPA 99, 3-3.3.4.2 Line Isolation Monitor Tests. The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following: (a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated. (b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators. (c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.
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The facility failed to provide a Type 1 Essential Electrical System (EES) per code. Findings include:

During the survey, per documentation provided by the facility, generator #1 was installed in 2006 - the EES was not divided into the three separate branches.
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1999 NFPA 99, 3-4.2.2.2 Emergency System. (a) General. Those functions of patient care depending on lighting or appliances that are permitted to be connected to the emergency system are divided into two mandatory branches, described in 3-4.2.2.2(b) and (c). +All ac-powered support and accessory equipment necessary to the operation of the EPS shall be supplied from the load side of the automatic transfer switch(es), or the output terminals of the EPS, ahead of the main EPS overcurrent protection, as necessary, to ensure continuity of the EPSS operation and performance. (NFPA 110: 5-12.5) (b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment: 1. Illumination of means of egress as required in NFPA 101,? Life Safety Code? 2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code 3. Alarm and alerting systems including the following: a. Fire alarms b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems" 4. * Hospital communication systems, where used for issuing instruction during emergency conditions 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location 6. Elevator cab lighting, control, communication, and signal systems 7. Automatically operated doors used for building egress. No function other than those listed above in items 1 through 7 shall be connected to the life safety branch. Exception: The auxiliary functions of fire alarm combination systems complying with NAPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch. (c) * Critical Branch. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches. 1. Critical care areas that utilize anesthetizing gases, task illumination, selected receptacles, and fixed equipment 2. The isolated power systems in special environments 3. Patient care areas - task illumination and selected receptacles in the following: a. Infant nurseries b. Medication preparation areas c. Pharmacy dispensing areas d. Selected acute nursing areas e. Psychiatric bed areas (omit receptacles) f. Ward treatment rooms g. Nurses' stations (unless adequately lighted by corridor luminaires) 4. Additional specialized patient care task illumination and receptacles, where needed 5. Nurse call systems 6. Blood, bone, and tissue banks 7. * Telephone equipment rooms and closets 8. Task illumination, selected receptacles, and selected power circuits for the following: a. General care beds (at least one duplex receptacle per patient bedroom) b. Angiographic labs c. Cardiac catheterization labs d. Coronary care units e. Hemodialysis rooms or areas f. Emergency Room treatment areas (selected) g. Human Physiology Labs h. Intensive Care Units i. Postoperative Recovery Rooms (selected) 9. Additional task illumination, receptacles, and selected power circuits needed for effective facility operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.