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Based on observations and interview, it was determined the facility failed to ensure one 45-minute fire rated door, protecting a hazardous storage area, could automatically close to a latched position.

Findings include:

Observations during tour on 08/10/22 between 9:30 a.m. and 10:30 a.m. with Staff A (Director of Facilities) revealed the 45-minute fire rated door assembly located in the basement level, between the utility area and the "Dirt Cellar" (labeled) failed to automatically close to a latched position when released from the full open position. The automatic door closing device failed to provide enough pressure for the full closure. The cellar area is being used to store large quantities of paper records inside of cardboard boxes.

Interview on 08/10/22 with Staff A confirmed the above findings, location, and conditions.

Based on observations and interview, it was determined the facility failed to ensure penetrations through smoke/fire, barriers/partitions, were properly sealed in at least four separate locations.

Findings include:

Observations during tour on 08/10/22 between 9:30 a.m. and 2:30 p.m. with Staff A (Director of Facilities) revealed unsealed penetrations through barriers and partitions in the following locations:
1. On the left hand side of the Dirt Cellar ceiling, about half way down the room, there is an unsealed penetration with an insulated hot water pipe and 1 1/2" electrical conduit, passing through the concrete ceiling deck above.
2. Inside the ROH (Ray of Hope) mechanical room, there are two unsealed penetrations through the smoke resistant partitions, from a recently installed mini-split system. The HVAC lines on both sides of the mini-split failed to be sealed to a smoke resistant condition as well as one of the roof trusses.
3. The computer server room, located in the Administration wing, has two unsealed electrical conduits passing through the smoke resistant ceiling.
4. The Main Mechanical room has at least three unsealed penetrations through the upper walls from one steel roof truss, and several "IT" (Internet Technologies) wires (recently added).

Interview on 08/10/22 with Staff A confirmed the above findings, locations, and existing conditions.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (2011 edition)

11.4 Inspection for Grease Buildup. The entire exhaust system shall be inspected for grease buildup by a properly trained, qualified and certified person(s) acceptable to the authority having jurisdiction and in accordance with table 11.4.
Table 11.4
Volume of Cooking Inspection Frequency
Solid fuel cooking Monthly
24-Hour cooking Quarterly
Moderate volume Semi-annual
Low Volume Annually
11.6.1 Upon inspection, if the exhaust system is found to be contaminated with deposits from grease-laden vapors, the contaminated portions of the exhaust system shall be cleaned by a properly trained, qualified, and certified person(s) acceptable to the AHJ.

11.2 Inspection, Testing, and Maintenance of Fire Extinguishing Systems
11.2.1 Maintenance of the fire extinguishing systems and listed hoods containing a constant or fire actuated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified persons acceptable to the authority having jurisdiction at least every 6 month's.
11.2.4 Fusible links of the metal alloy type and automatic sprinkler of the metal alloy type shall be replaced at least semiannually.

Based on record review and interview, it was determined the facility failed to ensure the main Kitchen exhaust system (moderate volume) was cleaned on the required semi-annual basis (6 months)and the the Ansul R-102 suppression system was serviced on the required semi-annual basis (6 months).

Findings include:

Record review during tour on 08/09/22 between 11:00 a.m. and 1:00 p.m. with Staff A (Director of facilities) revealed the main Kitchen commercial exhaust system was cleaned on 11/05/20 then again on 06/24/21 (over 7 1/2 months). The next two cleanings were completed on time. Additionally, the documentation of the Ansul suppression system, protecting the commercial Kitchen appliances, failed to be available for a semi-annual basis. The documented services were on 02/22/21 and 02/11/22. The documents for an August 2021 service failed to be located.

Interview on 08/10/22 with Staff A confirmed the above findings and available documentation.

















11.6.2 Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to remove combustible contaminants prior to the surfaces becoming heavily contaminated with grease or oily sludge.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (2011 edition)
6.3.2 Hydrostatic Tests.
6.3.2.1 Hydrostatic tests of not less than 200 psi pressure for 2 hours, or at 50 psi in excess of the maximum pressure, where maximum pressure is in excess of 150 psi, shall be conducted every 5 years on manual standpipe systems and semi-automatic dry standpipe systems, including piping in the fire department connection.
6.3.3.2 Hydrostatic tests shall be conducted in accordance with 6.3.2.1 on any system that has been modified or repaired.
6.3.2.3.1 The inside standpipe piping shall show no leakage.

Chapter 14 Obstruction Investigation
14.2 Internal Inspection of Piping.
14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material.
14.2.1.1 Alternative nondestructive examination methods shall be permitted.
14.2.1.2 Tubercules or slime, if found, shall be tested for indications of microbiologically influenced corrosion (MIC).
14.2.1.3 If the presence of sufficient foreign organic or inorganic material is found to obstruct pipe or sprinklers, an obstruction investigation shall be conducted as described in section 14.3.
14.2.1.4 Non-metallic pipe shall not be required to be inspected internally.
14.2.1.5 In dry pipe systems and pre-action systems, the sprinkler removed shall be from the most remote branch line from the source of water that is not equipped with the inspector's test valve.

Based on record review and interview, it was determined the facility failed to ensure the four sprinkler systems received the five year obstruction testing, FDC (Fire Department Connections) hydrostatic testing, and the air and water gauges are tested or replaced every five years.

Findings include:

Record review during tour on 08/09/22 between 12:00 p.m. and 2:00 p.m. with Staff A (Director of Facilities) revealed the four sprinkler systems, buildings covered, and overdue five year maintenance and testing requirements are as follows:
1. The main Hospital wet sprinkler system # 1, last received the obstruction and FDC testing on 03/16/16 and was due for the five year obstruction and FDC hydrostatic testing on 03/16/21. The air and water gauges were also dates 03/16/16 and were due for replacement or comparative testing on 03/16/21.
2. The main Hospital wet sprinkler system # 2, last received the obstruction and FDC testing on 03/16/16 and was due for the five year obstruction and FDC hydrostatic testing on 03/16/21. The air and water gauges were also dated
3. The RHC (Rowe Health Center) building's wet sprinkler system last received the final acceptance and FDC acceptance in the fall of 2015 (new) (exact date undetermined) and was due for the five year obstruction and FDC hydrostatic testing in the fall of 2020. The air and water gauges were also dated 2015 and due for replacement or comparative testing in the fall of 2020.
4. The RHC (Rowe Health Center) building's dry type sprinkler system last received the final acceptance and FDC acceptance in the fall of 2015 (new) (exact date undetermined) and was due for the five year obstruction and FDC hydrostatic testing in the fall of 2020. The air and water gauges were also dated 2015 and due for replacement or comparative testing in the fall of 2020.

Interview on 08/09/22 with Staff A confirmed the above findings, available documentation, dates recorded on the four separate sprinkler system riser inspection tags, as well as the most recent sprinkler system vendor inspection reports dated 05/12/22.

NFPA 1 Fire Code (2009 edition)
60.1.15 Protection from vehicles.
60.1.15.1 Guard posts or other approved means shall be provided to protect the following areas where subject to vehicular damage:
(1) Storage tanks and connected piping, valves, and fittings.
(2) Dispensing areas.
(3) Use areas.

60.1.15.2 Where guard posts are installed, the post shall meet the following criteria:
(1) They shall be constructed of steel not less than 4" in diameter and concrete filled.
(2) They shall be spaced not more than 4' ft. between posts on center.
(3) They shall be set not less than 3 ft deep in a concrete footing of not less than 15" in. diameter.
(4) They shall be set with the top of the post at not less than 3' ft. above ground.

Based on observations and interview, it was determined the facility failed to ensure two liquid propane distribution pipes are protected from accidental damage, snow removal, or delivery vehicles.

Findings include:

Observations on 08/10/22 between 7:30 a.m. and 8:30 a.m. with Staff A (Director of Facilities) revealed the two LP distribution pipes, from the bulk tank storage area, rise out of the ground in front of the loading dock area, on the left hand side. The two pipes are approximately 6" inches in front of the loading dock and 4" inches away from an outside corner of the facility. These two pipes, approximately 14" tall, are easily accessible to vehicular damage without any protective barriers in place, such as steel bollards or a concrete barrier.

Interview on 08/10/22 with Staff A confirmed the above findings, location, and potential risk associated with gas distribution piping damage.

Based on record review and interview, it was determined the facility failed to conduct 2nd shift fire drills at varied and unexpected times on a quarterly basis for each shift. Additionally, the RHC ( Rowe Health Center) failed to conduct one semi-annual fire drill.

Findings include:

Record review on 08/09/22 between 9:00 a.m. and 10:00 a.m. with Staff A (Director of Facilities) revealed the 2nd shift failed to conduct one fire drill for the 3rd quarter of 2021 and failed to conduct fire drills at varied and unexpected times, and the facility failed to conduct one fire drill on a semi-annual basis for the RHC (Rowe Health Center):

Main Hospital
2nd shift 7:00 p.m. - 7:00 a.m.
06/23/22 8:35 p.m.
05/27/22 9:25 p.m.
01/21/22 9:18 p.m.
10/31/22 9:00 p.m.
not conducted
05/21/21 9:15 p.m.
01/29/21 9:18 p.m.
10/22/20 9:00 p.m.
Covid waiver
Covid waiver
03/27/20 5:57 p.m.
12/17/19 8:25 p.m.

RHC held their last fire drill on 08/04/21. A semi-annual fire drill should have been conducted around February 2022 with no documentation available. A fire drill had been scheduled for 08/10/22.

Interview on 08/10/22 with Staff A confirmed the above findings and available documentation.

NFPA 110 Standard for Emergency and Standby Power Systems

5.6.5 Control Functions
5.6.5.1 A control Panel shall be provided and shall contain the following:
1. Automatic remote start capability
2. "Run-off-automatic" switch
3. Shutdowns as required by 5.6.5.2 (3)
4. Alarms as required by 5.6.5.2 (4)
5. Controls as required by 5.6.5.2 (5)
5.6.5.2 Where a control panel is mounted on the energy converter, it shall be mounted by means of anti-vibration shock mounts, if required, to maximize reliability. An automatic control and safety panel shall be part of the EPS containing the following equipment, or possess the following characteristics, or both:
5.6.5.2 (3) Controls to shutdown and lock out the prime mover under any of the following conditions:
(a) Failure to start after a specified cranking time
(b) Over-speed
(c) Low lubricating oil pressure
(d) High engine temperature
(e) Operation of the remote manual stop station

5.6.5.6 All installations shall have a remote manual stop station of a type to prevent inadvertent operation located outside the room housing the prime mover, or where so installed, or elsewhere on the premises where the prime mover is located outside the building.

8.3.5* Transfer switches shall be subject to an annual maintenance and testing program that includes all of the following operations:
1. Checking of connections
2. Inspection or testing for evidence of overheating and excessive contact erosion
3. Removal of all dust and dirt
4. Replacement of contacts when required

8.3.7 Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturers specifications.
8.3.7.1 Maintenance of lead acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.
8.3.7.2 Defective batteries shall be replaced immediately upon discovery of defects.

Based on record review, observations, and interview, it was determined the facility failed to ensure the 500 KW emergency Generator received a 4-hour load bank test every 36 months and the "emergency stop button" failed to be located outside of the Generator housing container.

Findings include:

Record review and observations during tour 08/09/22 and 08/10/22 with Staff A (Director of Facilities) revealed the 4-hour load bank testing was conducted on 01/09/16 and again on 07/14/19 (for a total time of over 42 months). The current 36 month 4-hour load testing has been scheduled for the 3rd week of August 2022 (for a total time of 37 months). Additionally, the existing "emergency stop button" is located inside the Generator housing container on the main control panel, which needs to be mounted on the exterior
of the housing container for safe access during an emergency situation.

Interview on 08/10/22 with Staff A confirmed the above findings, conditions, and available documentation.