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The facility failed to ensure doors to hazardous areas in fully sprinklered existing health care occupancies were equipped with self-closing/automatic latching hardware.

Observation determined:
1) The corridor door to the Storage Room near the elevator did not have a self-closing device.
2) The corridor door to the Clean Linen/Storage Room did not have a self-closing device.

Failure to ensure doors to hazardous areas self-close and latch to the door frame increases the risk or death or injury due to fire.

This deficiency affected two (2) of nine (9) hazardous areas in the facility.

The facility failed to maintain the means of egress as required.

Observation determined the northeast exit door from the building required excessive force to open.

Failure to maintain the means of egress as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of five (5) exits from the facility.

The facility failed to conduct quarterly fire drills on each shift.

Record review showed fire drills were not conducted on the following shifts:
1) First shift did not conduct a drill during the first, second, and third quarter of 2014.
2) Second shift did not conduct a drill during the first and third quarter of 2014.

Failure to conduct fire drills as required increases the risk of death or injury due to fire.

This deficiency affected five (5) of eight (8) required fire drills in the past year.

The facility failed to test the fire alarm system as required.

Review of the fire alarm test records indicated:
1) The facility failed to conduct a monthly test of the fire alarm system. Records indicate the fire alarm system was not tested in December 2013 and January, February, June, July, and August 2014.
2) The semiannual load voltage tests of the sealed lead acid batteries were not performed as required. Records indicated a load voltage test of the fire alarm system batteries was conducted by an outside company during the annual inspection in March 2014. Records and interview of maintenance staff determined no other load voltage test of the batteries was done in the past year. Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 table 7-3.2 item 6.d.3.

Failure to test the fire alarm system as required increases the risk of death or injury due to fire.

This deficiency affected numerous tests of the fire alarm system. The fire alarm system serves the entire building.

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

Heat from a fire stratifies to the ceiling and travels along the ceiling to activate the sprinkler. When ceilings are removed, it delays the activation of the automatic fire sprinkler system.

All backflow devices installed in fire protection water supply shall be tested annually at the designed flow rate of the fire protection system, including hose stream demands, if appropriate.
Exception: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be conducted at the maximum flow rate possible.

Review of records and observation determined:
1) Several ceiling tiles were missing from the suspended ceiling in the Server Room. Approximately half the room was missing ceiling tiles.

This deficiency affected one (1) of numerous rooms in the facility.

2) On 11/24/2014, no record of the required annual back flow preventer test was available.

The deficiency affected one of numerous required tests of the automatic sprinkler system.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.5, 1998 NFPA 25 Section 9-6.2

3) The facility failed to conduct quarterly tests of the sprinkler system as required. Review of records and interview of maintenance staff determined a quarterly flow test of the automatic sprinkler system was not done in the fourth quarter of 2013 and the second quarter of 2014.

The deficiency affected two (2) of four (4) required quarterly flow tests of the automatic sprinkler system in the past year.

Failure to test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

The automatic sprinkler system serves the entire building.

Fire extinguishing systems for commercial cooking operations must meet NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. NFPA 96 requires an inspection and servicing of the fire-extinguishing system be made at least every 6 months by properly trained and qualified persons.

The facility failed to inspect and service the fire-extinguishing system at least every 6 months.

Review of the records determined the cooking equipment fire extinguishing system was inspected by an outside company on 09/30/2013 and 08/26/2014. The time period exceeded 6 months.

Failure to inspect and service the fire extinguishing system in accordance with NFPA 96 increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) fire extinguishing system for commercial cooking operation in the building.

The gas content of medical gas piping systems must be readily identifiable by appropriate labeling with the name and pressure of the gas contained at intervals of not more than 20 feet and at least once in each room and each story traversed by the piping system. Such labeling must be by means of metal tags, stenciling, stamping, or adhesive markers, in a manner that is not readily removable. NFPA 99, 4-3.1.2.14. The facility failed to ensure appropriate labeling with the name and pressure of the gas contained in the copper pipes that supply oxygen to patient care areas throughout the facility.Observation determined the piping in the Oxygen Supply Room for the oxygen supply manifold had no markings or labels applied to the piping to indicate the content of the gas line.

Failure to properly label oxygen piping increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) oxygen supply system in the facility.

The facility failed to ensure anesthetizing locations were protected in accordance with NFPA 99, Standard for Health Care Facilities.

Interview with maintenance staff indicated the relative humidity was not monitored in the Operating Room.

Failure to ensure anesthetizing locations are protected in accordance with NFPA 99 increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) operating room location in the facility.

A functional test must be conducted on every required emergency lighting system at 30-day intervals for a minimum of 30 seconds. An annual test must be conducted for 1 1/2-hour duration. Written records of testing must be kept by the owner for inspection by the authority having jurisdiction.

The facility failed to ensure the emergency lighting system operated as required.

Observation determined the battery backup emergency light near the nurses station failed to illuminate when tested.

Failure to maintain emergency lighting increases the risk of death or injury due to fire.

This deficiency affected one (1) of four (4) emergency battery back-up lights.

The facility failed to provide maintenance of fire dampers in a reliable operating condition as required by NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. Maintenance of fire dampers is required at least every 6 years in a hospital. Maintenance of fire dampers includes:

(a) Fusible links shall be removed.
(b) All dampers shall be operated to verify that they close fully.
(c) The latch, if provided, shall be checked.
(d) Moving parts shall be lubricated as necessary.

Review of records and interview of maintenance staff indicated the last inspection and maintenance of the fire dampers was done by an outside company on March 6, 2008, exceeding 6 years.

Failure to maintain fire dampers in accordance with NFPA 90A increases the risk of death or injury due to fire.

This deficiency affected the fire dampers throughout the entire facility.

The facility failed to ensure the oxygen supply system and all components were in accordance with the requirements for a Type I Gas System. NFPA 99, Chapter 4. Observation determined the medical gas system alarm panel, with an audible and visual alarm, was not installed at an attended location.

Failure to ensure oxygen supply systems comply with NFPA 99 increases the risk of death or injury due to fire.The deficiency affected the entire facility.

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.

All Level 1 and Level 2 installations of an emergency generator shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. NFPA 110, 3-5.5.6

For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. NFPA 110, A-3-5-5-6
Maintenance of emergency generator batteries should include checking and recording the value of the specific gravity. NFPA 110, Section A-6-3.6

Observation and review of records determined:
1) There was not an emergency stop switch at a location external to the weatherproof enclosure of the emergency generator. The emergency generator was located outside.

2) The batteries in the emergency generator were not tested for specific gravity.

Failure to ensure the emergency generator is in compliance with NFPA 110 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power for the building.

The facility failed to ensure doors to hazardous areas in fully sprinklered existing health care occupancies were equipped with self-closing/automatic latching hardware.

Observation determined:
1) The corridor door to the Storage Room near the elevator did not have a self-closing device.
2) The corridor door to the Clean Linen/Storage Room did not have a self-closing device.

Failure to ensure doors to hazardous areas self-close and latch to the door frame increases the risk or death or injury due to fire.

This deficiency affected two (2) of nine (9) hazardous areas in the facility.

The facility failed to maintain the means of egress as required.

Observation determined the northeast exit door from the building required excessive force to open.

Failure to maintain the means of egress as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of five (5) exits from the facility.

The facility failed to conduct quarterly fire drills on each shift.

Record review showed fire drills were not conducted on the following shifts:
1) First shift did not conduct a drill during the first, second, and third quarter of 2014.
2) Second shift did not conduct a drill during the first and third quarter of 2014.

Failure to conduct fire drills as required increases the risk of death or injury due to fire.

This deficiency affected five (5) of eight (8) required fire drills in the past year.

The facility failed to test the fire alarm system as required.

Review of the fire alarm test records indicated:
1) The facility failed to conduct a monthly test of the fire alarm system. Records indicate the fire alarm system was not tested in December 2013 and January, February, June, July, and August 2014.
2) The semiannual load voltage tests of the sealed lead acid batteries were not performed as required. Records indicated a load voltage test of the fire alarm system batteries was conducted by an outside company during the annual inspection in March 2014. Records and interview of maintenance staff determined no other load voltage test of the batteries was done in the past year. Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 table 7-3.2 item 6.d.3.

Failure to test the fire alarm system as required increases the risk of death or injury due to fire.

This deficiency affected numerous tests of the fire alarm system. The fire alarm system serves the entire building.

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

Heat from a fire stratifies to the ceiling and travels along the ceiling to activate the sprinkler. When ceilings are removed, it delays the activation of the automatic fire sprinkler system.

All backflow devices installed in fire protection water supply shall be tested annually at the designed flow rate of the fire protection system, including hose stream demands, if appropriate.
Exception: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be conducted at the maximum flow rate possible.

Review of records and observation determined:
1) Several ceiling tiles were missing from the suspended ceiling in the Server Room. Approximately half the room was missing ceiling tiles.

This deficiency affected one (1) of numerous rooms in the facility.

2) On 11/24/2014, no record of the required annual back flow preventer test was available.

The deficiency affected one of numerous required tests of the automatic sprinkler system.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.5, 1998 NFPA 25 Section 9-6.2

3) The facility failed to conduct quarterly tests of the sprinkler system as required. Review of records and interview of maintenance staff determined a quarterly flow test of the automatic sprinkler system was not done in the fourth quarter of 2013 and the second quarter of 2014.

The deficiency affected two (2) of four (4) required quarterly flow tests of the automatic sprinkler system in the past year.

Failure to test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

The automatic sprinkler system serves the entire building.

Fire extinguishing systems for commercial cooking operations must meet NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. NFPA 96 requires an inspection and servicing of the fire-extinguishing system be made at least every 6 months by properly trained and qualified persons.

The facility failed to inspect and service the fire-extinguishing system at least every 6 months.

Review of the records determined the cooking equipment fire extinguishing system was inspected by an outside company on 09/30/2013 and 08/26/2014. The time period exceeded 6 months.

Failure to inspect and service the fire extinguishing system in accordance with NFPA 96 increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) fire extinguishing system for commercial cooking operation in the building.

The gas content of medical gas piping systems must be readily identifiable by appropriate labeling with the name and pressure of the gas contained at intervals of not more than 20 feet and at least once in each room and each story traversed by the piping system. Such labeling must be by means of metal tags, stenciling, stamping, or adhesive markers, in a manner that is not readily removable. NFPA 99, 4-3.1.2.14. The facility failed to ensure appropriate labeling with the name and pressure of the gas contained in the copper pipes that supply oxygen to patient care areas throughout the facility.Observation determined the piping in the Oxygen Supply Room for the oxygen supply manifold had no markings or labels applied to the piping to indicate the content of the gas line.

Failure to properly label oxygen piping increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) oxygen supply system in the facility.

The facility failed to ensure anesthetizing locations were protected in accordance with NFPA 99, Standard for Health Care Facilities.

Interview with maintenance staff indicated the relative humidity was not monitored in the Operating Room.

Failure to ensure anesthetizing locations are protected in accordance with NFPA 99 increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) operating room location in the facility.

A functional test must be conducted on every required emergency lighting system at 30-day intervals for a minimum of 30 seconds. An annual test must be conducted for 1 1/2-hour duration. Written records of testing must be kept by the owner for inspection by the authority having jurisdiction.

The facility failed to ensure the emergency lighting system operated as required.

Observation determined the battery backup emergency light near the nurses station failed to illuminate when tested.

Failure to maintain emergency lighting increases the risk of death or injury due to fire.

This deficiency affected one (1) of four (4) emergency battery back-up lights.

The facility failed to provide maintenance of fire dampers in a reliable operating condition as required by NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. Maintenance of fire dampers is required at least every 6 years in a hospital. Maintenance of fire dampers includes:

(a) Fusible links shall be removed.
(b) All dampers shall be operated to verify that they close fully.
(c) The latch, if provided, shall be checked.
(d) Moving parts shall be lubricated as necessary.

Review of records and interview of maintenance staff indicated the last inspection and maintenance of the fire dampers was done by an outside company on March 6, 2008, exceeding 6 years.

Failure to maintain fire dampers in accordance with NFPA 90A increases the risk of death or injury due to fire.

This deficiency affected the fire dampers throughout the entire facility.

The facility failed to ensure the oxygen supply system and all components were in accordance with the requirements for a Type I Gas System. NFPA 99, Chapter 4. Observation determined the medical gas system alarm panel, with an audible and visual alarm, was not installed at an attended location.

Failure to ensure oxygen supply systems comply with NFPA 99 increases the risk of death or injury due to fire.The deficiency affected the entire facility.

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.

All Level 1 and Level 2 installations of an emergency generator shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. NFPA 110, 3-5.5.6

For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. NFPA 110, A-3-5-5-6
Maintenance of emergency generator batteries should include checking and recording the value of the specific gravity. NFPA 110, Section A-6-3.6

Observation and review of records determined:
1) There was not an emergency stop switch at a location external to the weatherproof enclosure of the emergency generator. The emergency generator was located outside.

2) The batteries in the emergency generator were not tested for specific gravity.

Failure to ensure the emergency generator is in compliance with NFPA 110 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power for the building.