Penobscot Valley Hospital

“Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This Standard is not met as evidenced by: 42159 Based on observation, the facility failed to ensure that the fire proofing applied to the structural steel beams supporting the second level is maintained to achieve the required fire protection in accordance with NFPA 101, Life Safety Code, 2012 edition, Section 19.1.6. Finding: On 08/19/2025, between 11:00 AM and 4:00 PM, a surveyor, with the Maintenance Tech present, observed the following: 1. The fireproofing on the steel beam in Room 153 was scraped off in many locations. Please ensure that all fireproofing is intact on all required applications. The surveyor confirmed this finding with the Maintenance Tech at the time of the observation during the facility tour.”

“Interior Nonbearing Wall Construction CFR(s): NFPA 101 Interior Nonbearing Wall Construction Interior nonbearing walls in Type I or II construction are constructed of noncombustible or limited-combustible materials. Interior nonbearing walls required to have a minimum 2 hour fire resistance rating are permitted to be fire-retardant-treated wood enclosed within noncombustible or limited-combustible materials, provided they are not used as shaft enclosures. 19.1.6.4, 19.1.6.5 This Standard is not met as evidenced by: 50034 Based on observations the Hospital failed to comply with the National Fire Protection Association Life Safety Code, 2012 Edition. Interior nonbearing walls required to have a minimum 2 hour fire resistance rating are permitted to be fire-retardant-treated wood enclosed within noncombustible or limited-combustible materials, provided they are not used as shaft enclosures. 19.1.6.4, 19.1.6.5 Findings: During a survey on 08/19/2025 during the hours of 11:00 AM and 4:00 PM, a surveyor with the Maintenance Tech present observed the following: 1. In Room 153 a metal pipe was penetrating the 2-hour fire-barrier wall with no fire-stopping present. 2. In Room 189 a metal pipe was penetrating the 2-hour fire-barrier wall with no fire-stopping present. 3. In Room 150 there was a 1 1/4 inch medical gas pipe penetration the 2-hour fire-barrier with no fire-stopping present. These findings were confirmed by the surveyor and Maintenance Tech at the time of the facility tour.”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 50034 Based on observations, the facility failed to ensure that doors at the means of egress meet the requirements of NFPA 101 life safety code 2012 edition sections 7.2.1.5.3 and 7.2.1.6.2 under requirements for door locks, latches, and alarm devices. Findings: On 08/19/2025 between 11:00 AM & 4 PM, a surveyor, with the Maintenance Tech present, observed the following: 1. The cross corridor doors that are part of a smoke barrier have top and bottom latching devices but the bottom latches do not latch as there is no striker plate in the floor or fire pins present. 2. The cross corridor egress exit door near patient room 103 has a keypad with no access code attached and no delayed egress for the door. 3. The same cross corridor door near patient room 103 going into the hospital has a turn dial that unlocks the door for 15 minutes but does not allow the door to latch securely for that time frame nor does it have delayed egress for that door. The surveyor confirmed these findings with the Maintenance Tech at the time of observation. ccc”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 42159 Based on observation, the facility failed to ensure that doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of required manual fire alarm system, and local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and automatic sprinkler system, if installed; and loss of power per the requirements of NFPA 101, Life Safety Code, 2012 edition, Section 19.2.2.2.7. Findings: On 08/19/2025, between 11:00 AM and 4:00 PM, a surveyor, with the Maintenance Tech present, observed the following: 1. The 45 minute fire rated door to the bathroom in the Doctor’s Lounge was not equipped with a self-closing device. The door shall self-close and positively latch as it’s part of a 1-hour fire rated wall assembly and it is a fire rated door. 2. Rooms #38 and #190 have door closers that are not connected to the door, preventing them from self-closing and latching as designed. The surveyor confirmed these findings with the Maintenance Tech at the time of the observation during the facility tour.”

“Discharge from Exits CFR(s): NFPA 101 Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7 This Standard is not met as evidenced by: 50034 Based on observation, the facility failed to ensure that exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface in accordance with survey and and certification letter 05-38. On 08/18/2025, between 11:00 AM and 4:00 PM, a surveyor, with a Maintenance Tech present, observed the following: 1. The SNF Unit (Station 2) does not exit onto a level surface and does not lead back to a public way. The surveyor confirmed these findings with the Maintenance Tech at the time of observation.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 42159 Based on observations and interviews with the Maintenance Tech, the facility failed to maintain and install the illuminated exit signage in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition sections 7.10.1.9, 7.10.5.2.1, and 19.2.10. Findings include: On 08/19/2025, between 11:00 AM and 4:00 PM, a surveyor, with the Maintenance Tech present, observed the following: 1. There is not illuminated exit signage identifying the exit pathway from the vestibule into Zone 6 by the cross corridor doors. 2. The illuminated exit sign by Patient Room 103 did not remain illuminated when the test button was pressed. The surveyor confirmed these findings with the Maintenance Tech at the time of the observation during the facility tour.”

“Interior Wall and Ceiling Finish CFR(s): NFPA 101 Interior Wall and Ceiling Finish 2012 EXISTING Interior wall and ceiling finishes, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and have a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted. 10.2, 19.3.3.1, 19.3.3.2 Indicate flame spread rating(s). _____________________ This Standard is not met as evidenced by: 50034 Based on observations the Hospital failed to comply with the National Fire Protection Association Life Safety Code, 2012 Edition. Interior wall and ceiling finishes, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and have a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted. 10.2, 19.3.3.1, 19.3.3.2 Findings: During a survey on 08/19/2025 during the hours of 11:00 AM and 4:00 PM, a surveyor with the Maintenance Tech present observed the following: 1. In the nurse break room (above the ceiling) there is exposed foam board insulation that does not have the required thermal barrier/covering per Title 25 section 2447-B of the state statue. This finding was confirmed by the surveyor and Maintenance Tech at the time of the facility tour.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 42159 Based on observation and interview, the long-term care facility failed to install the water-based fire protection system throughout the premises in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 edition, Section 8.6.3.4.1 as referenced by NFPA 101, Life Safety Code, 2012 edition, Section 19.3.5. Finding: On 08/19/2025, between 11:00 AM and 4:00 PM, a surveyor, with the Maintenance Tech present, observed the following: 1. Two sprinkler heads are installed less approximately 3-4 feet apart by Patient Room 103. The minimum spacing for pendant sprinkler heads without obstructions between them is 6 feet. The surveyors acknowledged this finding with the Maintenance Tech at the time of the observation during the facility tour.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 42159 Based on observation during the facility tour the facility failed to install the portable fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers 2010 edition, Section 6.1.3.8.1 as referenced by NFPA 101, Life Safety Code, 2012 Edition, Sections 9.7.4.1., and 19.3.5.12. On 08/19/2025, between 11:00 AM and 4:00 PM, a surveyor, with the Maintenance Tech present, observed the following during the facility tour. Findings: 1. Fire extinguishers having a gross weight not exceeding 40 lb shall be installed so that the top of the fire extinguisher is not more than 5 ft above the floor. The fire extinguisher located in the nurses’ station across from ICU is mounted on the wall approximately 5’ 4 ¼” off the finished floor to the top of the extinguisher. This finding was confirmed by this surveyor and the Maintenance Tech at the time of the observation during the facility tour..”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 42159 Based on observation, the long-term care facility failed to maintain the corridor doors to resist the passage of smoke to and from the corridor by latching as referenced by NFPA 101, Life Safety Code 2012 edition, Section 19.3.6.3 Findings: On 08/19/2025, between 11:00 AM and 4:00 PM, a surveyor, with the Maintenance Tech present, observed the following: 1. Roller latches are installed on the patient room cabinets in the corridor. The cabinets were used for trash and combustible storage. 2. The dining room door to the corridor isn’t equipped with latching hardware. The corridor doors shall positively latch. 3. Room 190 across from the Nurse’s station shall self close and latch. The door is not equipped with a closing device. 4. Room 38 across from the Nurse’s station shall self close and latch. The door is not equipped with a closing device. 5. Zone 1 Oxygen storage room didn’t latch. The surveyor confirmed these findings with the Maintenance Tech at the time of the observation during the facility tour. 50034 Based on observation, the long-term care facility failed to maintain the corridor doors to resist the passage of smoke to and from the corridor by latching as referenced by NFPA 101, Life Safety Code 2012 edition, Section 19.3.6.3 Findings: On 08/19/2025, between 11:00 AM and 4:00 PM, a surveyor, with the Maintenance Tech present, observed the following: 1. Room 116 does not latch when closed. This was attempted x 4 times unsuccessfully. The surveyor confirmed this finding with the Maintenance Tech ad the time of observation during the facility tour.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 39983 Based on observations and document review, the facility failed to ensure that the generator had proper maintenance records and was being exercised in accordance with the auxiliary generator power per NFPA 110 Section 8.4.9 Finding: Based on document review and interview on 08/19/2025 between the hours of 11:00 AM and 4:00 PM. surveyors 39983 and 51673 accompanied by the Plant Engineer did observe the following: 1. The generator records for the EES indicate that the generator has not been tested for the required 4 continuous hours since October 2020. This requirement applies to all generator types if they supply a Level 1 EPSS. The Plant Engineer stated “due to a change of staff and reorganization of facility preventative maintenance schedules, this inspection was missed” The surveyor confirmed this observation with the Plant Engineer at the time of the document review.”