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This Standard is not met as evidenced by:

Based on a review of emergency preparedness documentation and staff interview, the facility failed to meet the requirements of CFR Section 482.15(a)(4)

Section 482.15(a)(4) requires the facility to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. *

Findings Include:

A review of the facility's Emergency Preparedness Plan conducted on 8/15/23 indicates that the plan fails to establish a process for cooperation and collaboration with State or Federal emergency preparedness officials. The plan does establish a process for cooperation and collaboration with local and regional authorities but fails to include mention of State or Federal emergency preparedness officials.

As a result of failing to include a process for cooperation and collaboration with State and Federal emergency preparedness officials, the facility failed to ensure compliance with the requirements of CFR Section 482.15(a)(4).

This deficient practice could affect all patients in the event of an actual emergency where State or Federal emergency officials/agencies must be contacted.

The finding was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on review of emergency preparedness documentation and staff interview, the facility failed to meet the requirements of CFR Section 482.15(b)(1)

Section 482.15(b)(1) requires the facility to develop, establish and maintain a comprehensive Emergency Preparedness Program that specifically addresses alternate sources of energy to maintain emergency lighting, fire detection, extinguishing, alarm systems, and sewage and waste disposal in the event staff and patients evacuate the facility or shelter in place.

Findings Include:

A review of the facility's Emergency Preparedness Plan conducted on 8/15/23 indicates that the plan fails to provide information as to what alternate sources of energy the facility provides to specifically maintain emergency lighting, fire detection, extinguishing, alarm systems, and sewage and waste disposal in the event staff and patients evacuate the facility or shelter in place. The plan does include information relevant to an onsite 275 kw emergency generator but fails to mention if the above listed systems are provided emergency power by the generator or other sources in the event of normal power failure.

This deficient practice could affect all facility staff and residents in the event of a normal power loss and lack of an alternate power source to provide emergency power to the facility's emergency lighting, fire detection, extinguishing, and alarm systems, and sewage and waste disposal.

The finding was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on a review of emergency preparedness documentation and staff interview, the facility failed to meet the requirements of CFR Section 482.15(b)(2)

Section 482.15(b)(2) requires the facility to include in its emergency plan a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the facility must document the specific name and location of the receiving facility or other locations.

Findings Include:

A review of the facility's Emergency Preparedness Plan conducted on 8/15/23 indicates that the facility failed to provide a system to track the location of on-duty staff whether they shelter in place during an emergency or whether they are relocated during an emergency. The facility does provide a system to track patients sheltering in place, however the system does not include the addresses of MOU (memorandum of understanding) facilities that would accept patients in the event they may need to be relocated during an emergency event.


This deficient practice could affect all staff and patients in the event of an actual emergency that involve sheltering in place or relocation.

The finding was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on review of emergency preparedness documentation and staff interview, the facility failed to meet the requirements of CFR Section 482.15(b)(4)

Section 482.15(b)(4) requires the facility to include within its policies and procedures a means to shelter in place for patients, staff, and volunteers who remain in the facility during an emergency where evacuation is not warranted.

Findings Include:

A review of the facility's Emergency Preparedness Plan conducted on 8/15/23 indicates that the plan fails to provide within its policies and procedures a means to shelter in place for patients, staff, and volunteers who remain in the facility during an emergency where evacuation is not warranted and the directive is to shelter in place.

This deficient practice could affect all facility patients, staff and volunteers in the event of an emergency where shelter in place is the directive.

The finding was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This standard is not met as evidenced by:

Based on review of emergency preparedness documentation and staff interview, the facility failed to meet the requirements of CFR Section 482.15(b)(8)

Section 482.15(b)(8) requires the facility to provide a policy and procedure that addresses the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. In addition facility policies and procedures must specifically address the facility 's role in emergencies where the President declares a major disaster or emergency under the Stafford Act or an emergency under the National Emergencies Act, and the HHS Secretary declares a public health emergency.


Findings Include:

A review of emergency preparedness documentation and an interview with the facility staff, conducted on 8/15/2023 indicates that the policies and procedures of the facility's emergency preparedness program fails to include information about the 1135 waiver process and what may be required in the event of needing an 1135 waiver.

As a result of the finding the facility is found to be non-compliant with section 482.15(b)(8) of CFR 42.

This deficient practice could affect all patients and staff in the event of an actual emergency where an understanding of the 1135 waiver process becomes necessary.


The finding was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on review of emergency preparedness documentation and staff interview, the facility failed to meet the requirements of CFR Section 482.15(c)(1)

Section 482.15(c)(1) states that the facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years.

For Hospitals at §482.15(c) the communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [hospitals and CAHs].
(v) Volunteers.

Findings Include:

A review of the facility's Emergency Preparedness Plan conducted on 8/15/23 indicates that the plan fails to provide contact information relevant to:

1. Patients' physicians
2. Other [hospitals and CAHs]
3. Volunteers (if utilized)

This deficient practice could affect all facility staff and residents in the event of an emergency where the above listed information is needed.

The finding was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on review of emergency preparedness documentation and staff interview, the facility failed to meet the requirements of CFR Section 482.15(c)(2).

Section 482.15(c)(2) states that the facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years. The communication plan must include all of the following:

(2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.

Findings Include:

A review of the facility's Emergency Preparedness Plan conducted on 8/15/23 indicates that the plan fails to provide contact information relevant to Federal and State emergency preparedness staff.

This deficient practice could affect all facility staff and residents in the event of an emergency where the above listed information is needed.

The finding was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on review of emergency preparedness documentation and staff interview, the facility failed to meet the requirements of CFR Section 482.15(c)(4)-(6).

Section 482.15(c)(2) states that the facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years. The communication plan must include all of the following:

(4) A method for sharing information and medical documentation for patients under the facility's care, as necessary, with other health providers to maintain the continuity of care.

(5) A means in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii)

(6) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4).


Findings Include:

A review of the Emergency Management Plan (EMP) conducted on 8/15/23 found an Electronic Medical Record Disaster Plan and Recovery. However, the policy pertained to accessing and recovering patient information within the facility. No information or policies related to the following were provided:

1. A method for sharing information and medical documentation for patients under the facility's care.

2. A means, in the event of an evacuation, to release patient information.

3. A means of providing information about the general condition and location of patients under the facility's care.

This deficient practice could affect all facility staff and residents in the event of an emergency where the above listed information is needed.

The finding was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This standard is not met as evidenced by:

Based on review of emergency preparedness documentation and staff interview, the facility failed to meet the requirements of CFR Section 482.15(d)

Section 482.15(d) states the facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.


Findings Include:

A review of emergency preparedness documentation and an interview with facility staff, conducted on 8/15/2023 indicates that the facility has not developed a written training and testing program that meets the requirements of CFR 482(d).

The finding was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This standard is not met as evidenced by:

Based on review of emergency preparedness documentation and staff interview, the facility failed to meet the requirements of CFR Section 482.15(d)(1)

Section 482.15(d)(1) requires that the facility develop a training program that does all of the following:
1. Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, and volunteers, consistent with their expected roles.
2. Provide emergency preparedness training at least annually.
3. Maintain documentation of the training.
4. Demonstrate staff knowledge of emergency procedures.


Findings Include:

A review of the facility's Emergency Preparedness Plan, conducted on 8/15/23, indicates that the facility has not implemented a Training Program compliant with the requirements listed above in Section 482.15(d)(1). The plan, as reviewed, does not include any information as to a Training Program.

As a result of the finding the facility is found to be non-compliant with section 482.15(d)(1) of CFR 42.

The finding was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on review of emergency preparedness documentation and staff interview, the facility failed to meet the requirements of CFR Section 482.15(d)(2)

Section 482.15(d)(2) requires the following relevant to Testing:

The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.


Findings Include:

A review of the facility's Emergency Preparedness Plan conducted on 8/15/23 indicates that the facility failed to conduct exercises to test the emergency plan during the 2022 calendar year. The last recorded test/drill was an active shooter drill conducted in conjunction with the local police department on 10/27/2021.

As a result of failing to conduct emergency preparedness drills during the 2022 calendar year, the facility failed to ensure compliance with CFR Section 482.15(d)(2).

This deficient practice could affect all facility staff and residents in the event of an actual emergency.

The finding was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

Based on observations and records provided, the facility failed to properly maintain the automatic emergency generator system.

NFPA 99 section 6.4.4.1.1.3 states maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8.

NFPA 110 (8.3 Maintenance and Operational Testing.)
Section 8.3.1 states that the EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.

Section 8.3.2 states a routine maintenance and operational testing program shall be initiated immediately after the EPSS has passed acceptance tests or after completion of repairs that impact the operational reliability of the system.

Section 8.3.2.1 states the operational test shall be initiated at an ATS and shall include testing of each EPSS component on which maintenance or repair has been performed, including the transfer of each automatic and manual transfer switch to the alternate power source, for a period of not less than 30 minutes under operating temperature.

Section 8.3.3 states a written schedule for routine maintenance and operational testing of the EPSS shall be established.

Section 8.3.4 states a permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.

Section 8.3.4.1 states the permanent record shall include the following:
(1) The date of the maintenance report.
(2) Identification of the servicing personnel.
(3) Notation of any unsatisfactory condition and the corrective
action taken, including parts replaced.
(4) Testing of any repair for the time as recommended by the
manufacturer.

Section 8.3.7 states that storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications.

Section 8.3.7.1 states that 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.

Section 8.3.7.2 states that Defective batteries shall be replaced immediately upon discovery of defects.

Section 8.3.8 (Fuel quality tests) states that a fuel quality test shall be performed at least annually using tests approved by ASTM standards.

Section 8.4.1 states EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

Section 8.4.2 states diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating.

Section 8.4.2.3 states diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.

NFPA 99 section 6.4.4.1.1.4 states the inspection/testing. criteria, conditions, and personnel requirements shall be in accordance with 6.4.4.1.1.4(A) through 6.4.4.1.1.4(C).
(A)* Test Criteria. Generator sets shall be tested 12 times a year, with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8.
(B) Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
(C) Test Personnel. The scheduled tests shall be conducted by competent personnel to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.

Findings Include:

On 08/15/23 and 08/16/23, while reviewing the facility's records as provided, the following was revealed:

The facility is equipped with a 275 kW diesel fueled emergency generator. The generator's name plate indicates that the generator is rated for 275 kW, 343.8 kVA, 208 V / 954 Amps, 3 phase with a 0.8 PF.

The following deficient practice(s) were noted:

1. The facility's most recently documented vendor inspection was a four (4) hour load bank test conducted on 02/11/22. More than 18 months has past since the date of survey and the vendor inspection.

As a result, the facility failed to comply with NFPA 110, Section 8.3.3 which states a written schedule for routine maintenance and operational testing of the EPSS shall be established.

2. The facility's failure to document ampere readings during the following months: August, September, October November and December of 2022, and during February of 2023 substantiates a failure to conduct monthly load testing as required by Section 8.4.1 and Section 8.4.2. Section 8.4.2 states diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes

3. The facility's documented monthly load test data provided: typically noted as 210 volts / 90 Amps; 210 Volts / 87 Amps; 210 Volts / 87 Amps (less than 10 percent of rated nameplate) failed to achieve at least 30% of the rated nameplate on a monthly basis, nor does the documentation record exhaust gas temperatures. In addition, the run time is noted as 0600 - 0630, and not actual hours of run. The analog and digital hours clocks mounted on the unit would note a specific time if actual hours of run were recorded. The facility's Director of Facilities Management stated that the hours clocks were not "accurate."

4. The most recently documented load bank test was conducted on 02/22/22, more than 18 months ago, exceeding the annual requirement.

As a result, the facility failed to comply with NFPA 110, Section 8.4.2 and Section 8.4.2.3.

5. The facility failed to perform a fuel quality test annually using approved ASTM standards.

As a result, the facility failed to comply with NFPA 110, section 8.3.8.

6. The facility failed to provide weekly battery electrolyte level inspections, and monthly battery testing and recording of electrolyte specific gravity or battery conductance testing. Note battery conductance testing shall be permitted in lieu of testing the specific gravity when applicable or warranted.

As a result, the facility failed to comply with NFPA 110, Section 8.3.7 and Section 8.3.7.1.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by staff, the facility failed to ensure that the building is of a conforming construction type. Table 19.1.6.2 requires buildings 3-stories in height to be of at least Type I (443), Type I (332) or Type II (222). If the building is fully sprinklered it may be of Type II (111) construction.

The Findings Include:

Observations while touring the facility on 08/15/23 and 08/16/23 and as noted in previous surveys, revealed that Building (#01) is of 3-story Type III (200) construction classification. This is due to the significant amount of exposed wood beams, wood floor joists, and wood studs observed when viewing above the non-rated ceiling tiles.
Note: Although there were numerous construction types observed during survey which Building #01 is comprised of, no two-hour separation was provided at the connection points, resulting in down grading the entire building to the lowest construction classification observed.

As a result of the building construction, the facility (Bldg #01) failed to comply with table 19.1.6.1.

This deficient practice could affect all residents, as well as an undetermined amount of staff and visitors in the event of an emergency where the building structure is compromised by an actual fire.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

NOTE: This item does not meet NFPA 101 Life Safety Code, 2012 edition; however it could possibly meet an alternative compliance with the Code (Fire Safety Evaluation System - FSES) under equivalency concepts of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2013 edition where such equivalency is requested and approved.

This Standard is not met as evidenced by:

Based on observations and confirmed by staff, the facility failed to ensure that all the buildings are of a conforming construction type. Table 19.1.6.1 requires buildings 4-stories in height or greater to be of at least Type I (443), Type I (332) or Type II (222).

THE FINDINGS INCLUDE:

During the morning hours of 08/15/23, it was observed that the East Building (#02) is 4-stories in height and of Type II (222) construction classification. The East Building is separated from the West Building with a 2-hour fire wall on each of the adjoining floor levels. The West Building is classified as a non-conforming 3-story Type III(200) construction classification. As a result, the conforming East Building must maintain a proper 2-hour separation from the non-conforming West Building. When viewing the basemen level 2-hour wall for structural integrity, the following items were observed:

1) The 90-min door leading into the office identified as room 030 was observed has being held open with a wood wedge.

2) The 90-min door leading into the area below stair #5 was observed to be held open with a cardboard box.

3) The main entrance to the facility was observed to have a large structural opening spanning the front door and adjoining windows. This opening utilizes a steel and concrete beam to span the opening. The beam appears to be supported by 8" x 8" square steel tubes with a concrete based wrap protecting the steel. It appears as though water has infiltrated these columns at the top where they rest under the beam on the exterior of the building. The concrete coating has broken apart on the corners of these tubes, leaving the steel exposed on the lobby side of the columns. Upon closer observations, it appears as though the steel tubing itself has a significant amount of deterioration due to the water infiltration. The exact extent of the damage can't be determined unless these columns are fully exposed to closely examine the severity of the situation.

This deficient practice could affect all patients, as well as an undetermined amount of staff and visitors in the event of an emergency where the building structure is compromised by an actual fire and the doors were required to contain the spread of fire.

As a result of the lack of 2-hour separation between the two different construction classifications, the 4-story building is no longer a complying construction classification as required by table 19.1.6.1. The building is required to be of at least a Type II (222) construction classification.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by staff, the facility failed to ensure that the means of egress is in accordance with Chapter 19. Section 19.2.1 states every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.

Section states 7.3.4.1 states the width of any means of egress, unless otherwise provided in 7.3.4.1.1 through 7.3.4.1.3, shall be as follows:
(1) Not less than that required for a given egress component in this chapter or Chapters 11 through 43
(2) Not less than 36 in. (915 mm) where another part of this chapter and Chapters 11 through 43 do not specify a minimum width.

19.2.7 states discharge from exits shall be arranged in accordance with Section 7.7.

Section 7.7.1.1 states yards, courts, open spaces, or other portions of the exit discharge shall be of the required width and size to provide all occupants with a safe access to a public way.

Section 7.10.8.3.1 states any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO
EXIT

Section 7.10.8.3.2 states the NO EXIT sign shall have the word NO in letters 2 in. (51 mm) high, with a stroke width of 3.8 in. (9.5 mm), and the word EXIT in letters 1 in. (25 mm) high, with the word EXIT below the word NO, unless such sign is an approved existing sign.

Section 19.2.5.7.3.2 states Patient Care Non-Sleeping Suite Number of Means of Egress shall comply with the following.
(A) Non-sleeping suites of more than 2500 ft2 (230 m2) shall have not less than two exit access doors remotely located from each other.
(B) One means of egress from the suite shall be directly to a corridor complying with 19.3.6.
(C) For suites requiring two means of egress, one means of egress from the suite shall be permitted to be into another suite, provided that the separation between the suites complies with the corridor requirements of 19.3.6.2 through 19.3.6.5.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 08/15/23 while viewing the exterior egress routes, the following items were observed:

1) Stairwell #5 exterior door which leads to the roof is not a required means of egress. This door is not equipped with a NO EXIT sign as required.

2) The Cafeteria has an exit door which is labeled as an exit. This door leads to a small grass lawn leading to a wall with an approximate 3' drop to the concrete side-walk below. This door is not a required means of egress as the room size does not mandate this second means of egress. This door is not equipped with a NO EXIT sign as required.

3) The basement level landing of exit stairway #3 is being used for the storage of various items which include a popcorn popping machine and several kitchen storage racks.

This deficient practice could affect an undetermined amount of patients, staff, and visitors in the event of an actual emergency situation where evacuation of the facility is necessary and these egress routes are utilized sending the occupants into an unsafe condition.

As a result, the facility failed to comply with section 7.7 requiring exits to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by staff, the facility failed to ensure that doors held open by magnetic devices release according to section 19.2.2.2.7 with the activation of a smoke detecting device.

Section 19.2.2.2.7 states any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the smoke compartment
or throughout the entire facility.

Section 7.2.1.8.2 states in any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, door leaves shall be permitted to be automatic-closing, provided that all of the following criteria are met:
(1) Upon release of the hold-open mechanism, the leaf becomes self-closing.
(2) The release device is designed so that the leaf instantly releases manually and, upon release, becomes self-closing, or the leaf can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door leaf release service in NFPA 72, National Fire Alarm and Signaling Code.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released and the door leaf becomes self-closing.
(5) The release by means of smoke detection of one door leaf in a stair enclosure results in closing all door leaves serving that stair.

NFPA 72 section 17.7.5.6.1 states smoke detectors that are part of an open area protection system covering the room, corridor, or enclosed space on each side of the smoke door and that are located and spaced as required by 17.7.3 shall be permitted to accomplish smoke door release service.

Section 17.7.3.2.3.1 states in the absence of specific performance-based design criteria, smooth ceiling smoke detector spacing shall be a nominal 30 ft (9.1 m).

Section 17.7.5.6.2 states smoke detectors that are used exclusively for smoke door release service shall be located and spaced as required by 17.7.5.6.

Section 17.7.5.6.3 states where smoke door release is accomplished directly from the smoke detector(s), the detector(s) shall be listed for releasing service.

Section 17.7.5.6.4 states smoke detectors shall be of the photoelectric, ionization, or other approved type.

Section 17.7.5.6.5 states the number of detectors required shall be determined in accordance with 17.7.5.6.5.1 through 17.7.5.6.5.4.

Section 17.7.5.6.5.1 states if doors are to be closed in response to smoke flowing in either direction, the requirements of 17.7.5.6.5.1(A) through 17.7.5.6.5.1(D) shall apply.
(A) If the depth of wall section above the door is 24 in. (610 mm) or less, one ceiling-mounted smoke detector shall be required on one side of the doorway only, or two wall-mounted detectors shall be required, one on each side of the doorway. Figure 17.7.5.6.5.1(A), part A or B, shall apply.
(B) If the depth of wall section above the door is greater than 24 in. (610 mm) on one side only, one ceiling-mounted smoke detector shall be required on the higher side of the doorway only, or one wall-mounted detector shall be required on both sides of the doorway. Figure 17.7.5.6.5.1(A), part D, shall apply.
(C) If the depth of wall section above the door is greater than 24 in. (610 mm) on both sides, two ceiling-mounted or wall mounted detectors shall be required, one on each side of the doorway. Figure 17.7.5.6.5.1(A), part F, shall apply.
(D) If a detector is specifically listed for door frame mounting, or if a listed combination or integral detector-door closer assembly is used, only one detector shall be required if installed in the manner recommended by the manufacturer's published instructions. Figure 17.7.5.6.5.1(A), parts A, C, and E, shall apply.

Section 17.7.5.6.6.1 states if ceiling-mounted smoke detectors are to be installed on a smooth ceiling for a single or double doorway, they shall be located as follows (Figure 17.7.5.6.5.3(A) shall apply):
(1) On the centerline of the doorway
(2) No more than 5 ft (1.5 m), measured along the ceiling and perpendicular to the doorway

THE FINDINGS INCLUDE:

During the morning hours of 08/15/23 while surveying the basement level, smoke detectors were observed for proper placement in order to perform an FSES analysis/computation. Because smoke detection is not provided in the corridors per NFPA 72 spacing requirements (30' on center), smoke detectors are required within 5' of the fire/smoke barrier doors if they are held open with magnetic devices. The 2-hour fire door separating the West Building from the East Building is held open with a magnetic device and a smoke detector is not located within 5' of the door. As there is approximately 14" on the East side and 26" on the West side from the door's head jamb to ceiling plain above, a smoke detector is required on the West side of the door no further than 5' away.

This deficient practice could affect all patients, as well as an undetermined amount of staff and visitors in the event of the door not releasing and closing during an emergency situation in this location.

As a result of the lack of a smoke detector and the doors being held open by a magnetic devices, the facility failed to comply with section 17.7.5.6.5.1 for proper smoke detection devices.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by staff, the facility failed to ensure that stairwells are constructed as required.

1. Section 7.1.3.2.1 states where this code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following:

(1) The separation shall have a minimum 1-hour fire resistance rating where the exit connects three or fewer stories.
(2) The separation specified in 7.1.3.2.1(1), other than an existing separation, shall be supported by construction
having not less than a 1-hour fire resistance rating.
(3) The separation shall have a minimum 2-hour fire resistance rating where the exit connects four or more stories,
unless one of the following conditions exists:
(a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire
resistance rating.
(b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating.
(c) The minimum 1-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative to the requirement of 7.1.3.2.1(3).
(4) Reserved.
(5) The minimum 2-hour fire resistance-rated separation required by 7.1.3.2.1(3) shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having a
minimum 2-hour fire resistance rating, unless otherwise permitted by 7.1.3.2.1(7).
(6) Structural elements, or portions thereof, that support exit components and either penetrate into a fire resistance-rated assembly or are installed within a fire resistance-rated wall assembly shall be protected, as a
minimum, to the fire resistance rating required by 7.1.3.2.1(1) or (3).
(7) In Type III, Type IV, and Type V construction, as defined in NFPA 220, Standard on Types of Building Construction (see 8.2.1.2), fire-retardant-treated wood enclosed in noncombustible or limited-combustible materials shall be permitted.
(8) Openings in the separation shall be protected by fire door assemblies equipped with door closer's complying
with 7.2.1.8.
(9) Openings in exit enclosures shall be limited to door assemblies from normally occupied spaces and corridors
and door assemblies for egress from the enclosure, unless one of the following conditions exists:
(a) Openings in exit passageways in mall buildings as provided in Chapters 36 and 37 shall be permitted.
(b) In buildings of Type I or Type II construction, as defined in NFPA 220, Standard on Types of Building
Construction (see 8.2.1.2), existing fire protection-rated door assemblies to interstitial spaces shall be permitted, provided that such spaces meet all of the following criteria:
i. The space is used solely for distribution of pipes, ducts, and conduits.
ii. The space contains no storage.
iii. The space is separated from the exit enclosure in accordance with Section 8.3.
(c) Existing openings to mechanical equipment spaces protected by approved existing fire protection-rated door assemblies shall be permitted, provided that the following criteria are met:
i. The space is used solely for non-fuel-fired mechanical equipment.
ii. The space contains no storage of combustible materials.
iii. The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
(10) Penetrations into, and openings through, an exit enclosure assembly shall be limited to the following:
(a) Door assemblies permitted by 7.1.3.2.1(9)
(b) Electrical conduit serving the exit enclosure
(c) Required exit door openings
(d) Ductwork and equipment necessary for independent stair pressurization
(e) Water or steam piping necessary for the heating or cooling of the exit enclosure
(f) Sprinkler piping
(g) Standpipes
(h) Existing penetrations protected in accordance with 8.3.5
(i) Penetrations for fire alarm circuits, where the circuits are installed in metal conduit and the penetrations are protected in accordance with 8.3.5
(11) Penetrations or communicating openings shall be prohibited between adjacent exit enclosures.
(12) Membrane penetrations shall be permitted on the exit access side of the exit enclosure and shall be protected
in accordance with 8.3.5.6.

2. Section 7.2.2.5.3.1 states that open spaces within the exit enclosure shall not be used for any purpose that has the potential to interfere with egress.



THE FINDINGS INCLUDE:

1. During the morning hours of 08/15/23, it was observed that stairwell #5 has a storage room below the landing. The room originally had two complying doors for access. One door which is 90-min rated also makes up the 2-hour building separation. The second rated door was removed at some point in time. There is currently a non-rated hollow-core door approximately 2' over from where the rated door was removed. It was not known why the rated door was removed as it happened prior to the Facilities Director starting his position.

2. During the morning hours of 8/15/23, observations revealed that the basement level landing of stairway #6 is being used for the storage of various items including mattresses, cardboard boxes, bedframes, and small bedroom furniture items.

This deficient practice could affect all patients, as well as an undetermined amount of staff and visitors in the event of an emergency where the building structure is compromised by an actual fire.

As a result of the stairwell construction, storage room access and utilization of an enclosed stairway landing used for storage, the facility failed to comply with section 7.1.3.2.1. and section 7.2.2.5.3.1 of the 2012 edition of NFPA 101 Life Safety Code.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This standard is not met as evidenced by the following:

Based on observations, the facility failed to ensure that stairways and smokeproof enclosures used as exits are in accordance with Chapter 7 Section 7.2 of the 2012 edition of NFPA 101 Life Safety Code.

Section 7.2.2.5.3.1 states that open spaces within the exit enclosure shall not be used for any purpose that has the potential to interfere with egress.

Findings Include:

While conducting the facility tour during the morning hours of 8/16/23 observations revealed that the basement level landing of stairway #3 is being used for the storage of various items including various size kitchen storage racks and a popcorn popping machine.

This deficient practice could affect all patients, as well as an undetermined amount of staff and visitors in the event of an emergency where the building structure is compromised by an actual fire.

As a result of the finding the facility failed to comply with NFPA 101 section 7.2.2.5.3.1

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by staff, suites are not separated as required.

Section 19.2.5.7.1.2 states suites shall be separated from the remainder of the building, and from other suites, by one
of the following:
(1) Walls and doors meeting the requirements of 19.3.6.2 through 19.3.6.5
(2) Existing approved barriers and doors that limit the transfer of smoke

Section 19.3.6.2.1 states corridor walls shall be continuous from the floor to the underside of the floor or roof deck above; through any concealed spaces, such as those above suspended ceilings; and through interstitial structural and mechanical spaces, unless otherwise permitted by 19.3.6.2.4 through 19.3.6.2.8.

Section 19.3.6.2.2 states corridor walls shall have a minimum 1/2-hour fire resistance rating.

Section 19.3.6.2.3 states corridor walls shall form a barrier to limit the transfer of smoke.

Section 19.3.6.2.4 states in smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.

Section 19.3.6.2.5 states existing corridor partitions shall be permitted to terminate at ceilings that are not an integral part of a floor construction if 60 in. (1525 mm) or more of space exists between the top of the ceiling subsystem and the bottom of the floor or roof above, provided that all the following criteria are met:
(1) The ceiling is part of a fire-rated assembly tested to have a minimum 1-hour fire resistance rating in compliance with the provisions of Section 8.3.
(2) The corridor partitions form smoke-tight joints with the ceilings, and joint filler, if used, is noncombustible.
(3) Each compartment of interstitial space that constitutes a separate smoke area is vented, in a smoke emergency, to
the outside by mechanical means having the capacity to provide not less than two air changes per hour but, in no case, a capacity less than 5000 ft3/min (2.35 m3/s).
(4) The interstitial space is not used for storage.
(5) The space is not used as a plenum for supply, exhaust, or return air, except as noted in 19.3.6.2.5(3).

Section 19.3.6.3.4 states a clearance between the bottom of the door and the floor covering not exceeding 1 in. (25 mm) shall be permitted for corridor doors.

THE FINDINGS INCLUDE:

During the afternoon hours of 08/15/23 while touring the 1st floor level, a suite (approximately 52' x 40') was determined to be present on the 1st floor level to the left of the lobby. This entire office area is considered a suite as all the corridor walls terminate at the ceiling tiles and the area is non-sprinklered. The current configuration does not limit the transfer of smoke as there are no suite doors present within the existing door frame. The existing door frame has an approximate opening of 7'-8" wide by 6'-8" high. It is unknown why these doors were removed as it happened prior to the Facilities Director starting his position.
Note: The wall where the doors were present extends to the decking above and serves as the suite enclosure.

This deficient practice could affect all patients, staff and visitors within the improperly separated suite and surrounding smoke zone.

As a result, the facility failed to comply with section 19.3.6.2.3 to limit the transfer of smoke in corridor walls.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by staff, suites are not separated as required.

Section 19.2.5.7.1.2 states suites shall be separated from the remainder of the building, and from other suites, by one
of the following:
(1) Walls and doors meeting the requirements of 19.3.6.2 through 19.3.6.5
(2) Existing approved barriers and doors that limit the transfer of smoke

Section 19.3.6.2.1 states corridor walls shall be continuous from the floor to the underside of the floor or roof deck above; through any concealed spaces, such as those above suspended ceilings; and through interstitial structural and mechanical spaces, unless otherwise permitted by 19.3.6.2.4 through 19.3.6.2.8.

Section 19.3.6.2.2 states corridor walls shall have a minimum 1/2-hour fire resistance rating.

Section 19.3.6.2.3 states corridor walls shall form a barrier to limit the transfer of smoke.

Section 19.3.6.2.4 states in smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, a corridor shall be permitted to be separated from all other areas by non-fire-rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke.

Section 19.3.6.2.5 states existing corridor partitions shall be permitted to terminate at ceilings that are not an integral part of a floor construction if 60 in. (1525 mm) or more of space exists between the top of the ceiling subsystem and the bottom of the floor or roof above, provided that all the following criteria are met:
(1) The ceiling is part of a fire-rated assembly tested to have a minimum 1-hour fire resistance rating in compliance with the provisions of Section 8.3.
(2) The corridor partitions form smoke-tight joints with the ceilings, and joint filler, if used, is noncombustible.
(3) Each compartment of interstitial space that constitutes a separate smoke area is vented, in a smoke emergency, to
the outside by mechanical means having the capacity to provide not less than two air changes per hour but, in no case, a capacity less than 5000 ft3/min (2.35 m3/s).
(4) The interstitial space is not used for storage.
(5) The space is not used as a plenum for supply, exhaust, or return air, except as noted in 19.3.6.2.5(3).

Section 19.3.6.3.4 states a clearance between the bottom of the door and the floor covering not exceeding 1 in. (25 mm) shall be permitted for corridor doors.

THE FINDINGS INCLUDE:

During the morning hours of 08/15/23 while touring the basement level, a suite was determined to be present due to a small corridor being eliminated. The portion of the corridor which was sealed was not done in accordance with corridor walls. The current configuration does not limit the transfer of smoke as there are excessive gaps around the enclosure.

This deficient practice could affect all patients, staff and visitors within the improperly separated suite and surrounding smoke zone.

As a result, the facility failed to comply with section 19.3.6.2.3 to limit the transfer of smoke in corridor walls.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

Based on record review and staff interview, the facility failed to test installed emergency lighting and failed to provide emergency task illumination at the facility transfer switches in accordance with LSC Section 39.2.9 and 7.9. Section 39.2.9.1 states that Emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

Section 7.9.2.3, states that the emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting due to any of the following:
(1) Failure of a public utility or other outside electrical power supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities

Findings include:

On 08/16/23, while conducting the record review, it was noted that the following battery packs had repeatedly failed monthly functional testing and no corrective action was taken. These emergency battery pack lighting devices are noted as # 109, # 99, # 91, and # 81.

The dates of documented failure include: 07/24/23, 06/23/23, 05/23/23, 04/25/23, 02/22/23, 01/24/23, 06/20/22, 05/19/22, 04/15/22, and 03/16/22.

On 08/16/23, battery pack # 99 and # 81 were verified as failing when the test button was depressed.

As a result, the facility failed to ensure compliance with NFPA 101 and the sections referenced above.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on observations, the facility failed to provide emergency lighting in all required locations.

Section 19.2.9.1 states emergency lighting shall be provided in accordance with Section 7.9.

Section 7.9.2.4 states emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, other than battery systems for emergency luminaires in accordance with 7.9.2.5, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

NFPA 110 section 7.3.1 states the Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access.

Section 7.3.2 states the emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

THE FINDINGS INCLUDE:

Observations during the morning hours of 08/15/23 revealed the electrical room containing the automatic transfer switch (ATS) is not equipped with battery-powered emergency lighting. Interview at the time of observation with the Facilities Director confirmed the lack of emergency back up lighting at these two locations.

This deficient practice could affect all patients, as well as an undetermined amount of staff and visitors in the event of an actual power failure where emergency power is required.

As a result, the facility failed to ensure compliance with NFPA 101 and NFPA 110 and the sections referenced above.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on observations, the facility failed to provide emergency lighting in all required locations.

Section 19.2.9.1 states emergency lighting shall be provided in accordance with Section 7.9.

Section 7.9.2.4 states emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, other than battery systems for emergency luminaires in accordance with 7.9.2.5, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

NFPA 110 section 7.3.1 states the Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access.

Section 7.3.2 states the emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

THE FINDINGS INCLUDE:

Observations during the morning hours of 08/16/23 revealed the electrical room containing the automatic transfer switch (ATS) is not equipped with battery-powered emergency lighting. Interview at the time of observation with the Facilities Director confirmed the lack of emergency back up lighting at these two locations.

This deficient practice could affect all patients, as well as an undetermined amount of staff and visitors in the event of an actual power failure where emergency power is required.

As a result, the facility failed to ensure compliance with NFPA 101 and NFPA 110 and the sections referenced above.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by staff, the facility failed to identify egress routes with the proper signage.

Section 19.2.10.1 states means of egress shall have signs in accordance with section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4.

Section 7.10.1.2.1 states exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.

Section 7.10.1.5.1 states access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.

Section 7.10.2.1 states a sign complying with 7.10.3, with a directional indicator showing the direction of travel, shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Section 7.7.6 states where approved by the authority having jurisdiction, exits shall be permitted to discharge to roofs or other sections of the building or an adjoining building where the following criteria are met:
(1) The roof construction has a fire resistance rating not less than that required for the exit enclosure.
(2) There is a continuous and safe means of egress from the roof.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 06/15/23 and 06/16/23, exit routes were observed for compliance. It was observed that Stairwell #5 exits to the roof of the basement structure. The roof is not equipped with a continuous and safe means of egress from the roof. The roof is covered in rubber, has pockets of standing water, no walkway or handrails are provided, and the surface is extremely slippery. This stairwell runs between the basement and 3rd floor levels. However, this stairwell is not a required means of egress as there is a horizontal exit adjacent to the stair door on floors 1, 2, and 3 along with a stairwell at each end of the corridor. The basement level has an exit to grade at this location and this stairwell does not extend to 4th floor level. The doors leading into stairwell #5 on floors 1, 2, and 3 have an exit sign directly above the doors identifying the stairwell as an exit. The actual exit in these locations is the 2-hour horizontal doors located adjacent to the stairwell #5. These horizontal doors on floors 1, 2, and 3 are not equipped with an exit sign.

This deficient practice could affect all patients as well as an undetermined amount of staff and visitors in the event of an actual emergency situation where evacuation of the facility is necessary from this basement level.

As a result, the facility failed to comply with Chapter 7 requiring egress routes to be clearly identifiable.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by staff, the facility failed to identify egress routes with the proper signage.

Section 19.2.10.1 states means of egress shall have signs in accordance with section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4.

Section 7.10.1.2.1 states exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.

Section 7.10.1.5.1 states access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.

Section 7.10.2.1 states a sign complying with 7.10.3, with a directional indicator showing the direction of travel, shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

THE FINDINGS INCLUDE:

During the morning hours of 08/15/23 while viewing the basement floor level, it was observed that the horizontal exit door leading from Building #01 (West) into Building #02 (East) is not equipped with and exit sign.

This deficient practice could affect all residents as well as an undetermined amount of staff and visitors in the event of an actual emergency situation where evacuation of the facility is necessary from this basement level.

As a result, the facility failed to comply with Chapter 7 requiring egress routes to be clearly identifiable.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by staff, the facility failed to ensure that hazardous areas/locations are maintained as required.

Section 19.3.2.1 states 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 8.7.1.

Section 19.3.2.1.1 states an automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9.

Section 19.3.2.1.2 states where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.

Section 19.3.2.1.3 states the doors shall be self-closing or automatic-closing.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 08/15/23 thru 08/16/23, the following items were observed regarding hazardous area locations:

1) The Boiler Room was observed to have an approximate 1' x 2' hole in the wall directly above the corridor door.

2) The door to room #108 is not equipped with a self-closing device as required. This room presently contains in excess of 50 banker type boxes filled with paper documents. Because the room is now utilized as a storage room, the door is required to have a self-closing device.

3) The non-sprinklered Main Electric Room door was found to be in the open position during survey. It was stated by staff that the door is propped open (by a milk crate) because the room gets to warm. It was further stated that condenser unit for the Kitchen walk-in cooler is located in this electric room, and trips out on thermal overload due to overheating.
Note: This door is equipped with a sign stating to keep the door closed at all times due to high voltage within the room. The room contains numerous electrical panels, breakers, and disconnects which non-authorized staff should not be able to access at any time.

These deficient practices could affect all current patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency situation where a fire was to develop in these hazardous locations.

As a result of the deficient practices listed above, the facility failed to comply with section 19.3.2.1 requiring hazardous areas/locations to be properly separated.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This standard is not met as evidenced by the following:

Based on observations, the facility failed to ensure that hazardous areas are protected in accordance with NFPA 101 Life Safety Code requirements.

-NFPA 101 section 19.3.2.1 states any hazardous area shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishment system in accordance with 8.7.1.

-Section 8.7.1.1 states protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3
(2) Protecting the area with automatic extinguishing systems in accordance with Section 9.7
(3) Applying both 8.7.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 11 through 43.

Findings Include:

While conducting the facility tour during the morning and afternoon hours of 8/15/23, observations revealed that the soiled utility rooms located on floors 2, 3 and 4 of the East building are not in compliance with Section 8.7.1.1 for the following reasons:

1. They are not equipped with automatic sprinkler protection. Note: The facility is surveyed as a "hospital" and therefore not required to be fully-sprinklered.

2. They are not constructed with a 1-hour fire rating. As observed, the walls above the suspended ceilings either have penetrations or are not continuous to the deck above. In addition the opening protectives (doors) are not provided with any indication of fire rating (a minimum of 45 minutes fire rating is required).

As a result of the findings the facility failed to ensure that all hazardous areas are compliant with Section 8.7.1.1 of the 2012 edition of NFPA 101 Life safety Code.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

Based on observations and confirmed by staff interview the facility to ensure compliancy with Chapter 19 of the 2012 edition of NFPA 101 "Life Safety Code." Chapter 19 "Existing Health Care Occupancies," section 19.3.2.5.1 states cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4.

Section 9.2.3 (Commercial Cooking Equipment.) states that commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96, Section 4.1.1 states that Cooking equipment used in processes producing smoke or grease-laden vapors shall be equipped with an exhaust system that complies with all the equipment and performance requirements of this standard.

NFPA 96, Section 4.1.2 states that All such equipment and its performance shall be maintained in accordance with the requirements of this standard during all periods of operation of the cooking equipment.

NFPA 96, Section 4.1.3 states that The following equipment shall be kept in working condition:
(1) Cooking equipment
(2) Hoods
(3) Ducts (if applicable)
(4) Fans
(5) Fire-extinguishing equipment
(6) Special effluent or energy control equipment

NFPA 96, Section 4.1.3.1 states that Maintenance and repairs shall be performed on all components at intervals necessary to maintain good working condition.

NFPA 96, Section 6.2.3.1 states that Grease filters shall be listed and constructed of steel or listed equivalent material.

NFPA 96, Section 6.2.3.2 states that Grease filters shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions.

NFPA 96, Section 6.2.3.3 states that Grease filters shall be arranged so that all exhaust air passes through the grease filters.

NFPA 96, Section 6.2.3.4 states that Grease filters shall be easily accessible and removable for cleaning.

NFPA 96, Section 6.2.3.5 states that Grease filters shall be installed at an angle not less than 45 degrees from the horizontal.


NFPA 96 (2011) section 10.2.6 states that automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable:
(1) NFPA 12
(2) NFPA 13
(3) NFPA 17
(4) NFPA 17 A

NFPA 96 Section 11.2.1 states that maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated 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 person(s) acceptable to the authority having jurisdiction at least
every 6 months.

NFPA 96, section 11.4 states that 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 states that schedule of Inspection for Grease Buildup for systems serving moderate-volume cooking operations shall be inspected semiannually.

Findings Include :

On 08/15/23 while conducting the record review and on 08/15/23 and 08/16/23 observation while conducting the facility tour and staff interview it was confirmed that the facility failed to maintain the commercial kitchen extinguishment system and hood as required.

The kitchen extinguishment system was serviced on 08/16/23 and on 01/18/22. The noted time between inspections of the kitchen extinguishment system was 19 months, exceeding the semi-annual service by 13 months.

The kitchen hood vendor noted the following deficiencies on the 06/28/23 inspection report:

1. Hood: There are holes in the hood that need to be sealed.

2. Duct: Not liquid tight. Electrical in duct. Each fan should have a separate duct when new fans are installed.

3. Fan: Electrical is exposed , they are not grease fans, exits building near combustible material. Forms grease dips/traps behind hood before fans, unable to reach parts of duct.

As a result, the facility failed to comply with NFPA 17, section 11.5, NFPA 96, section 11.2..1, and NFPA 96, section 11.4 (table 11.4).

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

Based on record review it was revealed that the facility failed to ensure the fire alarm system is maintained as required.
NFPA 101 (2012 edition) 4.6.12.1 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

NFPA 101, Section 19.3.4.1 General states health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

Section 9.6.1.3 states a fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

Section 14.2.2.2 states the delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

NFPA #72 (National Fire Alarm Code) section 14.2.2.1 states the property or building or system owner or the
owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system.

Section 14.2.2.2 states the delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

Section 14.4.5.3.1 states sensitivity shall be checked within 1 year after installation.

Section 14.4.5.3.2 states sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.

NFPA #72, Table 14.4.5 requires all devices to be tested annually.

Findings Include:

On 08/15/23 while reviewing the fire alarm inspection reports, the following was recorded:

1. The most recent facility fire alarm vendor inspection reports were dated 03/08/22 and 07/29/21. In addition, visual inspection of the main Fire Alarm Control Panel (FACP) shows two (2) of nine (9) batteries dated 09/22/22. It appears that the facility had fire alarm vendor inspection, testing and maintenance (ITM) on a semi-annual schedule in previous years, however, it has been 17 months since the facility can substantiate that the fire alarm system is inspected, tested and maintained as required.

This deficient practice could affect all patients, as well as an undetermined number of staff and visitors in the event of an actual emergency where the sprinkler system is required to be utilized.

As a result, the facility failed to comply with the above sections of NFPA #72 (National Fire Alarm Code) section 14.2.2.1, which states the property or building or system owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

Based on record review it was revealed that the facility failed to ensure the fire alarm system is maintained as required.
NFPA 101 (2012 edition) 4.6.12.1 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

NFPA 101, Section 19.3.4.1 General states health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

Section 9.6.1.3 states a fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

Section 14.2.2.2 states the delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

NFPA #72 (National Fire Alarm Code) section 14.2.2.1 states the property or building or system owner or the
owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system.

Section 14.2.2.2 states the delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

Section 14.4.5.3.1 states sensitivity shall be checked within 1 year after installation.

Section 14.4.5.3.2 states sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.

NFPA #72, Table 14.4.5 requires all devices to be tested annually.

Findings Include:

On 08/15/23 while reviewing the fire alarm inspection reports, the following was recorded:

The most recent facility fire alarm vendor inspection reports were dated 03/08/22 and 07/29/21. In addition, visual inspection of the main Fire Alarm Control Panel (FACP) shows two (2) of nine (9) batteries dated 09/22/22. It appears that the facility had fire alarm vendor inspection, testing and maintenance (ITM) on a semi-annual schedule in previous years, however, it has been 17 months since the facility can substantiate that the fire alarm system is inspected, tested and maintained as required.

This deficient practice could affect all patients, as well as an undetermined number of staff and visitors in the event of an actual emergency where the sprinkler system is required to be utilized.

As a result, the facility failed to comply with the above sections of NFPA #72 (National Fire Alarm Code) section 14.2.2.1, which states the property or building or system owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by staff, the facility failed to ensure that all required areas are protected by the automatic sprinkler system.

Section 19.3.5.3 states where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

Section 19.3.5.4 states the sprinkler system required by 19.3.5.1 or 19.3.5.3 shall be installed in accordance with 9.7.1.1(1).

Section 19.3.5.5 states in Type I and Type II construction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as non-sprinklered.

Section 9.7.1.1 states each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes
(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height

NFPA 13 section 8.6.4.1.1.1 states under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm) throughout the area of coverage of the sprinkler.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 08/16/23 while touring the facility, the following items were noted regarding the installation of the sprinkler system:

1) The Kitchen ceiling has three (3) 2' x 4' egg crate ceiling grids installed in lieu of ceiling tiles. The grids are not connected to any duct work and open to the ceiling cavity above the lay-in ceiling tiles. The space from the sprinkler deflector to the decking above is in excess of 12". It is not known why these grids were installed as this was done prior to the Facilities Director starting his position.

2) Large sections of the gypsum ceiling were observed as missing in numerous areas of the basement level. This was noted in electrical rooms, storage rooms, boiler room, closets, and miscellaneous spaces. The wood framing is exposed in all these locations where the gypsum is missing.

3) In the room identified as 315B, the sprinkler heads were observed above the lay-in ceiling tiles.
Note: This room appears to have been renovated within the past few years as it is has all new ceiling materials.

4) In the small room between 311 and 312 (the old operating rooms), the sprinkler heads were observed above the lay-in ceiling tiles.
Note: This room appears to have been renovated within the past few years as it is has all new ceiling materials.

This deficient practice could affect all current patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency situation where a fire were to develop in this electrical room.

As a result, the facility failed to comply with section 8.15.10.3 requiring 2-hour fire separation or full sprinkler protection per section 19.3.5.1.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

Based on record review and confirmed by staff interview, the facility failed to ensure that the automatic sprinkler system is maintained, tested, and inspected as required; In compliance with the 2012 edition of the Life Safety Code (LSC) and the 2011 edition of NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 101 (2012 edition) 4.6.12.1 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

NFPA 101 section 9.7.5 states that 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.

NFPA #25 section 4.1.1 states the property owner or designated representative shall be responsible for properly maintaining a water based fire protection system.

Section 4.1.1.1.1 states inspection, testing, maintenance, and impairment shall be implemented in accordance with procedures meeting those established in this document and in accordance with the manufacturer's instructions.

Section 4.1.1.2 states inspection, testing, and maintenance shall be performed by personnel who have developed competence through training and experience.

Section 5.3.1.1 states where required by this section, sample sprinklers shall be submitted to a recognized testing laboratory acceptable to the authority having jurisdiction for field service testing.

NFPA 25 (2011 edition), section 5.2.1.1 states that sprinklers shall be inspected from the floor level annually.

NFPA 25, section 5.2.2 (Pipe and Fittings.) states that sprinkler pipe and fittings shall be inspected annually from the floor level.

NFPA 25, section 5.2.5 states that waterflow alarm and supervisory alarm devices shall be inspected quarterly to verify that they are free of physical damage.

NFPA 25, Section 5.3.3.1 states that mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly.

NFPA 25, Section 5.3.3.2 states that vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually.

NFPA 25, Section 5.3.3.3 states that testing waterflow alarm devices on wet pipe systems shall be accomplished by opening the inspector 's test connection.

NFPA 25, Section 13.2.5 states that a main drain test shall be conducted annually at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves.

NFPA 25, Section 13.2.5.1 states that in systems where the sole water supply is through a backflow preventer and/or pressure reducing valves, the main drain test of at least one system downstream of the device shall be conducted on a quarterly basis.

Findings Include:

On 08/15/23 and 08/16/23, while conducting the surveyor record review, it was revealed that the facility documentation provided indicates that the facility's automatic sprinkler vendor provided Inspection, Testing, and Maintenance (ITM) of the automatic sprinkler system was conducted on: 12/28/22 and 06/01/22.

As a result, the facility failed to provide the following:

1) Facility vendor documentation failed to substantiate quarterly inspection, testing and maintenance (ITM) as required. Specifically, the facility failed to properly:
(a.) Test the waterflow alarm and main drain quarterly.
(b.) Test the supervisory alarm devices semi-annually.
(c.) Test the end-of-the-line (EOL) inspector's test connection (ITC) quarterly .

As a result of the finding, the facility is found to be non-compliant with section 5.3.3.1 and section 5.3.3.3.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on record review and confirmed by staff interview, the facility failed to ensure that the automatic sprinkler system is maintained, tested, and inspected as required; In compliance with the 2012 edition of the Life Safety Code (LSC) and the 2011 edition of NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

The facility is licensed for 114 beds. This deficient practice could affect all current 83 patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency situation where the sprinkler system is required to be utilized.

NFPA 101 (2012 edition) 4.6.12.1 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

NFPA 101 section 9.7.5 states that 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.

NFPA #25 section 4.1.1 states the property owner or designated representative shall be responsible for properly maintaining a water based fire protection system.

Section 4.1.1.1.1 states inspection, testing, maintenance, and impairment shall be implemented in accordance with procedures meeting those established in this document and in accordance with the manufacturer's instructions.

Section 4.1.1.2 states inspection, testing, and maintenance shall be performed by personnel who have developed competence through training and experience.

Section 5.3.1.1 states where required by this section, sample sprinklers shall be submitted to a recognized testing laboratory acceptable to the authority having jurisdiction for field service testing.

NFPA 25 (2011 edition), section 5.2.1.1 states that sprinklers shall be inspected from the floor level annually.

NFPA 25, section 5.2.2 (Pipe and Fittings.) states that sprinkler pipe and fittings shall be inspected annually from the floor level.

NFPA 25, section 5.2.5 states that waterflow alarm and supervisory alarm devices shall be inspected quarterly to verify that they are free of physical damage.

NFPA 25, Section 5.3.3.1 states that mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly.

NFPA 25, Section 5.3.3.2 states that vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually.

NFPA 25, Section 5.3.3.3 states that testing waterflow alarm devices on wet pipe systems shall be accomplished by opening the inspector 's test connection.

NFPA 25, Section 13.2.5 states that a main drain test shall be conducted annually at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves.

NFPA 25, Section 13.2.5.1 states that in systems where the sole water supply is through a backflow preventer and/or pressure reducing valves, the main drain test of at least one system downstream of the device shall be conducted on a quarterly basis.

Findings Include:

Findings Include:

On 08/15/23, while conducting the surveyor record review, it was revealed that the facility documentation provided indicates that the facility's automatic sprinkler vendor provided Inspection, Testing, and Maintenance (ITM) of the automatic sprinkler system was conducted on: 06/08/23 and 06/18/22. Additionally, the sprinkler valve tag on the sprinklers' main control valve had an inspection date of 12/22/22.

As a result, the facility failed to provide the following:

1) Facility vendor documentation failed to substantiate quarterly inspection, testing and maintenance (ITM) as required. Specifically, the facility failed to properly:
(a.) Test the waterflow alarm and main drain quarterly.
(b.) Test the supervisory alarm devices semi-annually.
(c.) Test the end-of-the-line (EOL) inspector's test connection (ITC) quarterly .

As a result of the finding, the facility is found to be non-compliant with section 5.3.3.1, section 5.3.3.1, and section 5.3.3.3.

2) The facility's documentation of the year of manufacture for sprinkler heads, and visual inspection of several corridor sprinkler heads on the basement and second floor level, confirmed 1971 sprinkler heads. The 1971 sprinkler heads are approximately 52 years old and have neither been replaced nor a representative sample sent for testing / analysis.

As a result of the finding, the facility is found to be non-compliant with section 5.3.1.1.1.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on record review and confirmed by staff interview, the facility failed to ensure that the automatic sprinkler system is maintained, tested, and inspected as required; In compliance with the 2012 edition of the Life Safety Code (LSC) and the 2011 edition of NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

The facility is licensed for 114 beds. This deficient practice could affect all current 83 patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency situation where the sprinkler system is required to be utilized.

NFPA 101 (2012 edition) 4.6.12.1 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

NFPA 101 section 9.7.5 states that 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.

NFPA #25 section 4.1.1 states the property owner or designated representative shall be responsible for properly maintaining a water based fire protection system.

Section 4.1.1.1.1 states inspection, testing, maintenance, and impairment shall be implemented in accordance with procedures meeting those established in this document and in accordance with the manufacturer's instructions.

Section 4.1.1.2 states inspection, testing, and maintenance shall be performed by personnel who have developed competence through training and experience.

Section 5.3.1.1 states where required by this section, sample sprinklers shall be submitted to a recognized testing laboratory acceptable to the authority having jurisdiction for field service testing.

Section 5.3.1.1.1 states where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be tested.

Section 5.3.1.2 states a representative sample of sprinklers for testing per 5.3.1.1.1 shall consist of a minimum of not less than four sprinklers or 1 percent of the number of sprinklers per individual sprinkler sample, whichever is greater.

Section 5.3.1.3 states where one sprinkler within a representative sample fails to meet the test requirement, all sprinklers within the area represented by that sample shall be replaced.

Section 5.3.1.1.1.1 states test procedures shall be repeated at 10-year intervals.

NFPA 25 (2011 edition), section 5.2.1.1 states that sprinklers shall be inspected from the floor level annually.

NFPA 25, section 5.2.2 (Pipe and Fittings.) states that sprinkler pipe and fittings shall be inspected annually from the floor level.

NFPA 25, section 5.2.5 states that waterflow alarm and supervisory alarm devices shall be inspected quarterly to verify that they are free of physical damage.

NFPA 25, Section 5.3.3.1 states that mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly.

NFPA 25, Section 5.3.3.2 states that vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually.

NFPA 25, Section 5.3.3.3 states that testing waterflow alarm devices on wet pipe systems shall be accomplished by opening the inspector 's test connection.

NFPA 25, Section 13.2.5 states that a main drain test shall be conducted annually at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves.

NFPA 25, Section 13.2.5.1 states that in systems where the sole water supply is through a backflow preventer and/or pressure reducing valves, the main drain test of at least one system downstream of the device shall be conducted on a quarterly basis.

Findings Include:

On 08/15/23, while conducting the surveyor record review, it was revealed that the facility documentation provided indicates that the facility's automatic sprinkler vendor provided Inspection, Testing, and Maintenance (ITM) of the automatic sprinkler system was conducted on: 06/08/23 and 06/18/22. Additionally, the sprinkler valve tag on the sprinklers' main control valve had documented an additional inspection date of 12/22/22.(The facility failed to provide a vendor report for the 12/22/22 date.)

As a result, the facility failed to provide the following:

1) Facility vendor documentation failed to substantiate quarterly inspection, testing and maintenance (ITM) as required. Specifically, the facility failed to properly:
(a.) Test the waterflow alarm and main drain quarterly.
(b.) Test the supervisory alarm devices semi-annually.
(c.) Test the end-of-the-line (EOL) inspector's test connection (ITC) quarterly .

As a result of the finding, the facility is found to be non-compliant with section 5.3.3.1 and section 5.3.3.3.

2) The facility's documentation of the year of manufacture of sprinkler heads, and visual inspection of several corridor sprinkler heads on the basement and second floor levels, confirmed the presence of 1971 sprinkler heads. The 1971 sprinkler heads, approximately 52 years old, have neither been replaced nor had a representative sample sent for testing / analysis.

As a result of the finding, the facility is found to be non-compliant with section 5.3.1.1.1.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by facility staff, the facility failed to ensure that the elevator is properly equipped with the Phase I and Phase II Firefighter's Service Requirements.

THE FINDINGS INCLUDE:

During the morning hours of 08/15/23 it was observed that the East Building has one elevator which travels five stories in height. The elevator travels between the basement and 4th floor level of this building. The elevator travels an approximate distance of 36' from the 1st floor which is the main access floor to the facility in an emergency situation for firefighting purposes. The elevator is not provided with the Firefighter's Service Requirements as required.

Because the patients of this facility are all mobile, this deficient practice has minimal impact on patients, staff, or visitors. There are two approved exit routes on the 4th floor level, and all other floors have a horizontal exit into the West Building.

As a result, the facility failed to comply with section 19.5.3.

This was reviewed with and acknowledged by the facility's Director of Facilities Management during the building tour. In addition, it was emailed to the Facilities Director and asked to share these findings with the Chief Executive Officer as this was inadvertently missed during the exit interview conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by staff, the facility failed to ensure that all required components of the Fire Safety Plans are contained in the Facility's written plans. This deficient practice could affect all patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency situation where relocation is required to be utilized.

Based on document review, the facility failed to provide a detailed written fire plan in accordance with the requirements and failed to properly train staff.

Section 19.7.1.8 states employees of health care occupancies shall be instructed in life safety procedures and devices.

Section (19.7.2.1 Protection of Patients) 19.7.2.1.1 states for health care occupancies, the proper protection
of patients shall require the prompt and effective response of health care personnel.

Section 19.7.2.1.2 states that the basic response required of staff shall include
the following:
(1) Removal of all occupants directly involved with the fire
emergency
(2) Transmission of an appropriate fire alarm signal to warn
other building occupants and summon staff
(3) Confinement of the effects of the fire by closing doors to
isolate the fire area
(4) Relocation of patients as detailed in the health care occupancy's
fire safety plan

Section 19.7.2.2 (Fire Safety Plan) states a written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire

Section 19.7.2.3.2 states all health care occupancy personnel shall be instructed in the use of the code phrase to ensure transmission of an alarm under any of the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system

Section 19.7.2.3.3 states personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings Include:

Review of the facility's fire plan on 08/15/23 and 08/16/23 and interview with Director of Facilities Management revealed that the facility's fire plan failed to provide the basic response required by and outlined in Section 19.7.2.1.2.

The facility's fire plan states:

Persons hearing the Code Phrase, "Fire Drill," shall immediately execute their duties and contact the switchboard, as outlined in this plan.

The facility's fire plan failed to include Section 19.7.2.3.2 stating all health care occupancy personnel shall be instructed in the use of the code phrase to ensure transmission of an alarm under any of the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system

As a result, the facilities fire plan failed to provide the following:

1. The facility's fire plan fails to ensure that personnel hearing the code announced, shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan, as per Section 19.7.2.3.3.

2. The facility's fire plan also fails to provide location of fire barrier and smoke barrier compartment walls (and the compartments), as noted in 19.7.2.2 (7).

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by staff, the facility failed to ensure that all required components of the Fire Safety Plans are contained in the Facility's written plans. This deficient practice could affect all patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency situation where relocation is required to be utilized.

Based on document review, the facility failed to provide a detailed written fire plan in accordance with the requirements and failed to properly train staff.

Section 19.7.1.8 states employees of health care occupancies shall be instructed in life safety procedures and devices.

Section (19.7.2.1 Protection of Patients) 19.7.2.1.1 states for health care occupancies, the proper protection
of patients shall require the prompt and effective response of health care personnel.

Section 19.7.2.1.2 states that the basic response required of staff shall include
the following:
(1) Removal of all occupants directly involved with the fire emergency
(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff
(3) Confinement of the effects of the fire by closing doors to isolate the fire area
(4) Relocation of patients as detailed in the health care occupancy's fire safety plan

Section 19.7.2.2 (Fire Safety Plan) states a written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire

Section 19.7.2.3.2 states all health care occupancy personnel shall be instructed in the use of the code phrase to ensure transmission of an alarm under any of the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system

Section 19.7.2.3.3 states personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings Include:

Review of the facility's fire plan on 08/15/23 and 08/16/23 and interview with Director of Facilities Management revealed that the facility's fire plan failed to provide the basic response required by and outlined in Section 19.7.2.1.2.

The facility's fire plan states:

Persons hearing the Code Phrase, "Fire Drill," shall immediately execute their duties and contact the switchboard, as outlined in this plan.

The facility's fire plan failed to include Section 19.7.2.3.2 stating all health care occupancy personnel shall be instructed in the use of the code phrase to ensure transmission of an alarm under any of the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system

As a result, the facilities fire plan failed to provide the following:

1. The facility's fire plan fails to ensure that personnel hearing the code announced, shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan, as per Section 19.7.2.3.3.

2. The facility's fire plan also fails to provide location of fire barrier and smoke barrier compartment walls (and the compartments), as noted in 19.7.2.2 (7).

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

Based on record review and staff interview with the Director of Facilities Management, the facility failed to ensure compliance with specific requirements of the 2012 edition of NFPA 101 Life Safety Code. This facility is licensed for 114-beds. This deficient practice could affect the current census of 83 patients, as well as an undetermined amount of staff and visitors in the event of an actual fire.

The facility failed to ensure that fire drills are conducted quarterly on each shift and documented accurately.

NFPA 101, chapter 19, section 19.7.1.6 states that fire 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.

NFPA 101, chapter 19, section 19.7.1.7 allows for when drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

NFPA 101, chapter 4, section 4.7.2 ( Drill Frequency.) states that Emergency egress and relocation drills, where required by Chapters 11 through 43 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.

NFPA 101, chapter 4, section 4.7.3 (Orderly Evacuation. ) states that when conducting drills, emphasis shall be placed on orderly evacuation rather than on speed.

NFPA 101, chapter 4, section 4.7.4 ( Simulated Conditions.) states that drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

NFPA 101, chapter 4, section 4.7.6 states that a written record of each drill shall be completed by the person responsible for conducting the drill and maintained in an approved manner.

NFPA 101, chapter 4, Annex A.4.7.6 states that the written record required by this paragraph should include such details as the date, time, participants, location, and results of that drill.

Findings include:

On 08/15/23, while performing the surveyor record review process and interview with the Director of Maintenance (DOM), the facility failed to properly conduct first (7:00 A.M. - 3:00 P.M.), second (3:00 P.M. - 11:00 P.M.), and third (11:00 P.M. - 7:00 A.M.) shift fire drills as required.

First shift fire drills were documented as follows:
- On 04/11/23, at 1:00 P.M.,
- On 01/06/23, at 1:00 P.M.,
- On 10/23/22, at 1:30 P.M.,
- On 08/17/22, at 1:30 P.M.,
- On 07/14/22, at 11:00 A.M.,
- On 04/21//22, at 2:00 P.M., and
- On 01/15/22, at 2:00 P.M.

Second Shift fire drills were documented as follows:
- On 07/13/23, at 4:00 P.M.,
- On 05/25/23, at 7:00 P.M.,
- On 02/10/23, at 5:00 P.M.,
- On 05/23/22, at 5:45 P.M., and
- On 02/19/22, at 5:15 P.M.

Third Shift fire drills were documented as follows:
- On 06/22/23, at 4:00 A.M.,
- On 03/24/23, at 2:00 A.M.,
- On 09/22/22, at 4:16 A.M.,
- On 06/29/22, at unspecified time and
- On 03/29/22, at unspecified time.

As a result, the facility failed to conduct the following:

1. The facility failed to conduct second shift fire drills during the fourth quarter (Oct./Nov./Dec.) of 2022 and third quarter (Jul./Aug./Sept.) of 2022. The facility also failed to vary the time(s) during the second shift fire drills as four (4) of five (5) documented fire drills were conducted between 4:00 P.M. and 5:00 P.M.

2. The facility failed to conduct third shift fire drills during the fourth quarter (Oct./Nov./Dec.) of 2022. The facility also failed to properly document the time of drill for the third shift fire drills as noted above.

3. Six (6) of seven (7) first shift fire drills were conducted between 1:00 P.M. and 2:00 P.M.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

Based on record review and staff interview with the Director of Facilities Management, the facility failed to ensure compliance with specific requirements of the 2012 edition of NFPA 101 Life Safety Code.

The facility failed to ensure that fire drills are conducted quarterly on each shift and documented accurately.

NFPA 101, chapter 4, section 4.7.2 ( Drill Frequency.) states that Emergency egress and relocation drills, where required by Chapters 11 through 43 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.

NFPA 101, chapter 4, section 4.7.3 (Orderly Evacuation. ) states that when conducting drills, emphasis shall be placed on orderly evacuation rather than on speed.

NFPA 101, chapter 4, section 4.7.4 ( Simulated Conditions.) states that drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

NFPA 101, chapter 4, section 4.7.6 states that a written record of each drill shall be completed by the person responsible for conducting the drill and maintained in an approved manner.

NFPA 101, chapter 4, Annex .4.7.6 states that the written record required by this paragraph should include such details as the date, time, participants, location, and results of that drill.

NFPA 101, Chapter 39, section 7.2 states thaw in all business occupancy buildings occupied by more than 500 persons, or by more than 100 persons above or below the street level, employees and supervisory personnel shall be periodically instructed in accordance with Section 4.7 and shall hold drills periodically where practicable.

Chapter 39, section 7.3 states that extinguisher training, designated employees of business occupancies shall be periodically instructed in the use of portable fire extinguishers.

Findings include:

On 08/15/23 and 08/16/23, while performing the surveyor record review process and interview with the Director of Facilities Management, the facility failed to properly conduct fire drills as required.

Fire drills were documented as follows:
- On 11/21/22, at 3:00 P.M.,
- On 04/02/21, at 9:20 A.M., and
- On 01/06/20, at 9:00 A.M.

As a result, the following deficient practices occured:

1. The most recent fire drill conducted was conducted almost nine (9) months ago.
2. The facility conducted one fire drill per year, calendar years 2022, 2021, and 2020. No documented fire drills have been conducted during calendar year 2023.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

Based on record review and confirmed by staff, the facility failed to ensure that doors are inspected and maintained in accordance with NFPA 101 Life Safety Code and NFPA 80, Standard for Fire Doors and Other Opening Protectives. This has a potential to affect an indeterminable number of facility residents, staff and visitors throughout the building.

-NFPA 101 Chapter 4 section 4.6.12.1 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

NFPA 80, Chapter 4, section 4.1.4.2.1, states that signs shall be attached to fire doors by use of an adhesive.

Section 4.1.4.2.2, states that mechanical attachments such as screws or nails shall not be permitted.

Section 4.1.4.3 states that signs shall not be installed on glazing material in fire doors.

Section 4.1.4.4 states that signs shall not be installed on the surface of fire doors so as to impair or otherwise interfere with the proper operation
of the fire door.

-NFPA 80, Chapter 5, Section 5.1.1.1 of NFPA 80 Standard for Fire Doors and Other Opening Protectives, (2010 edition) states this chapter shall cover the care and maintenance of fire doors and fire windows.

-Section 5.1.5.1 states repairs shall be made, and defects that could interfere with operation shall be corrected without delay.

-Section 5.2.15.3 states where a fire door, frame, or any part of its appurtenances is damaged to the extent that it could impair the door 's proper emergency function, the following actions shall
be performed:
(1) The fire door, frame, door assembly, or any part of its appurtenances shall be repaired with labeled parts or parts obtained from the original manufacturer.
(2) The door shall be tested to ensure emergency operation and closing upon completion of the repairs.

-Section 5.2.15.3.1 states if repairs cannot be made with labeled components or parts obtained from the original manufacturer or retrofitted in accordance with Section 5.3, the fire door frame,
fire door assembly, or appurtenances shall be replaced.

-Section 5.2.15.4 states when holes are left in a door or frame due to changes or removal of hardware or plant-ons, the holes shall be repaired by the following methods:
(1) Install steel fasteners that completely fill the holes
(2) Fill the screw or bolt holes with the same material as the door or frame.

-Section 5.2.1 states fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

-Section 5.2.3.1 states functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

-Section 5.2.3.2 states before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting.

-Section 5.2.4.1 states fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

-Section 5.2.4.2 states as a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order
with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity

Section 6.3.1.1, states that only labeled door frames shall be used.

Section 6.3.1.7.1, states that the clearances between the top and vertical edges of the door and the frame, and the meeting edges of doors swinging in pairs, shall be 1/8 in. +/- 1/16 in. for steel doors and shall not exceed 1/8 in. for wood doors.

6.3.1.7.2 Clearances shall be measured from the pull face of the door(s).

NFPA 101, section 8.3.3.2.3, states that labels on fire door assemblies shall be maintained in a legible condition.

Findings Include:

Document review on 08/15/23 and 08/16/23 indicated that an annual inspection/test of the facility's required fire door assemblies was not conducted during calendar years 2021, 2022, and 2023 through till the date of survey 08/16/23. The most recent "annual" fire door inspection was conducted on 02/18/20 by facility staff.

As a result of the findings, the facility failed to comply with the maintenance requirements of NFPA 101 and the annual fire assembly inspection requirement of NFPA 80, Section 5.2.1 .

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by staff the facility failed to ensure that portable space heaters are used in accordance with Section 19.7.8.

Section 19.7.8 states portable space heating-devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:

(1) Such devices are used only in non-sleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212 degrees F(100 degrees C).

THE FINDINGS INCLUDE:

While conducting the facility tour during the afternoon hours of 08/15/23, a portable electric space heater with a heating element capable of exceeding 212 degrees F (100 degrees C) was observed in the following locations:

1) The closet where the sprinkler main is located within room 043 in the basement.
2) The men's locker room identified as room 053 in the basement.

Upon closer observations, these devices were found as unplugged and non-operational at the time of survey.

This deficient practice could affect all patients, as well as an undetermined amount of staff and visitors in the event of the device igniting a fire.

As a result, the facility failed to comply with section 19.7.8 which prohibits portable heating devices unless meeting all of the criteria.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by staff, the facility failed to ensure that electrical systems are installed as required. Section 19.5.1.1 states utilities shall comply with the provisions of Section 9.1.

Section 9.1.2 states electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, 300.15 Boxes, Conduit Bodies, or Fittings -Where Required.
Fittings and connectors shall be used only with the specific wiring methods for which they are designed and listed.
Where the wiring method is conduit, tubing, Type AC cable, Type MC cable, Type MI cable, nonmetallic-sheathed
cable, or other cables, a box or conduit body shall be installed at each conductor splice point, outlet point, switch point, junction point, termination point, or pull point, unless otherwise permitted in 300.15(A) through (L).

Section 314.41 Covers. Metal covers shall be of the same material as the box or conduit body with which they are used, or they shall be lined with firmly attached insulating material that is not less than 0.79 mm (1.32 in.) thick, or they shall be listed for the purpose. Metal covers shall be the same thickness as the boxes or conduit body for which they are used, or they shall be listed for the purpose. Covers of porcelain or other approved insulating materials shall be permitted if of such form and thickness as to afford the required protection and strength.

NFPA 101 section 4.5.8 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained, unless the Code exempts such maintenance.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 08/15/23 & 08/16/23 while touring the facility on each of the floor levels, numerous electrical deficiencies were observed. While viewing above the ceiling tiles, numerous junction boxes were observed as having no cover plates with the wiring protruding from the junction boxes. Also, numerous wires (mainly romex) were observed as not terminating within a junction box, but rather just cut, spliced, and capped with wire nuts. When tested, these were all observed to be live with 120-volts. In addition, numerous wires were observed as just cut and left with exposed copper ends protruding. When tested, these were not live, but it is unknown if the capability exits for a breaker to be turned on and feed the circuit with electricity again. These items were mainly observed in the basement location of the electrical rooms and boiler/mechanical rooms. In addition to these locations, this condition existed above the ceiling tiles in almost every area which was viewed during survey.

This deficient practice could affect all staff working in the proximity of these wires with the possibility of electrocution. In addition, these conditions create a possible fire hazard as located in a Type III (200) combustible building.

As a result, the facility failed to comply with NFPA 70 and the above referenced codes.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by staff, the facility failed to ensure that electrical systems are installed as required. Section 19.5.1.1 states utilities shall comply with the provisions of Section 9.1.

Section 9.1.2 states electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, 300.15 Boxes, Conduit Bodies, or Fittings -Where Required.
Fittings and connectors shall be used only with the specific wiring methods for which they are designed and listed.
Where the wiring method is conduit, tubing, Type AC cable, Type MC cable, Type MI cable, nonmetallic-sheathed
cable, or other cables, a box or conduit body shall be installed at each conductor splice point, outlet point, switch point, junction point, termination point, or pull point, unless otherwise permitted in 300.15(A) through (L).

Section 314.41 Covers. Metal covers shall be of the same material as the box or conduit body with which they are used, or they shall be lined with firmly attached insulating material that is not less than 0.79 mm (1.32 in.) thick, or they shall be listed for the purpose. Metal covers shall be the same thickness as the boxes or conduit body for which they are used, or they shall be listed for the purpose. Covers of porcelain or other approved insulating materials shall be permitted if of such form and thickness as to afford the required protection and strength.

NFPA 101 section 4.5.8 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained, unless the Code exempts such maintenance.

THE FINDINGS INCLUDE:

During the morning and afternoon hours of 08/15/23 & 08/16/23 while touring the facility on each of the floor levels, numerous electrical deficiencies were observed. While viewing above the ceiling tiles, numerous junction boxes were observed has having no cover plates with the wiring protruding from the junction boxes. Also, numerous wires (mainly romex) were observed as not terminating within a junction box, but rather just cut, spliced, and capped with wire nuts. When tested, these were all observed to be live with 120-volts. In addition, numerous wires were observed as just cut and left with exposed copper ends protruding. When tested, these were not live, but it is unknown if the capability exits for a breaker to be turned on and feed the circuit with electricity. These items were mainly observed in the basement location of the electrical rooms and boiler/mechanical rooms. In addition to these locations, this condition existed above the ceiling tiles in almost every area which was viewed during survey.

This deficient practice could affect all staff working in the proximity of these wires with the possibility of electrocution. In addition, these conditions create a possible fire hazard without being properly safeguarded.

As a result, the facility failed to comply with NFPA 70 and the above referenced codes.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

Based on observations and records provided, the facility failed to properly maintain the automatic emergency generator system.

NFPA 99 section 6.4.4.1.1.3 states maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8.

NFPA 110 (8.3 Maintenance and Operational Testing.)
Section 8.3.1 states that the EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.

Section 8.3.2 states a routine maintenance and operational testing program shall be initiated immediately after the EPSS has passed acceptance tests or after completion of repairs that impact the operational reliability of the system.

Section 8.3.2.1 states the operational test shall be initiated at an ATS and shall include testing of each EPSS component on which maintenance or repair has been performed, including the transfer of each automatic and manual transfer switch to the alternate power source, for a period of not less than 30 minutes under operating temperature.

Section 8.3.3 states a written schedule for routine maintenance and operational testing of the EPSS shall be established.

Section 8.3.4 states a permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.

Section 8.3.4.1 states the permanent record shall include the following:
(1) The date of the maintenance report.
(2) Identification of the servicing personnel.
(3) Notation of any unsatisfactory condition and the corrective
action taken, including parts replaced.
(4) Testing of any repair for the time as recommended by the
manufacturer.

Section 8.3.7 states that storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications.

Section 8.3.7.1 states that 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.

Section 8.3.7.2 states that Defective batteries shall be replaced immediately upon discovery of defects.

Section 8.3.8 (Fuel quality tests) states that a fuel quality test shall be performed at least annually using tests approved by ASTM standards.

Section 8.4.1 states EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

Section 8.4.2 states diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating.

Section 8.4.2.3 states diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.

NFPA 99 section 6.4.4.1.1.4 states the inspection/testing. criteria, conditions, and personnel requirements shall be in accordance with 6.4.4.1.1.4(A) through 6.4.4.1.1.4(C).
(A)* Test Criteria. Generator sets shall be tested 12 times a year, with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8.
(B) Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
(C) Test Personnel. The scheduled tests shall be conducted by competent personnel to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.


Findings Include:

On 08/15/23 and 08/16/23, while reviewing the facility's records as provided, the following was revealed:

The facility is equipped with a 275 kW diesel fueled emergency generator. The generator's name plate indicates that the generator is rated for 275 kW, 343.8 kVA, 208 V / 954 Amps, 3 phase with a 0.8 PF.

The following deficient practice(s) were noted:

1. The facility's most recently documented vendor inspection was a four (4) hour load bank test conducted on 02/11/22. More than 18 months has past since the date of survey and the vendor inspection.

As a result, the facility failed to comply with NFPA 110, Section 8.3.3 which states a written schedule for routine maintenance and operational testing of the EPSS shall be established.

2. The facility's failure to document ampere readings during the following months: August, September, October November and December of 2022, and during February of 2023 substantiates a failure to conduct monthly load testing as required by Section 8.4.1 and Section 8.4.2. Section 8.4.2 states diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes

3. The facility's documented monthly load test data provided: typically noted as 210 volts / 90 Amps; 210 Volts / 87 Amps; 210 Volts / 87 Amps (less than 10 percent of rated nameplate) failed to achieve at least 30% of the rated nameplate on a monthly basis, nor does the documentation record exhaust gas temperatures. In addition, the run time is noted as 0600 - 0630, and not actual hours of run. The analog and digital hours clocks mounted on the unit would note a specific time if actual hours of run were recorded. The facility's Director of Facilities Management stated that the hours clocks were not "accurate."

4. The most recently documented load bank test was conducted on 02/22/22, more than 18 months ago, exceeding the annual requirement.

As a result, the facility failed to comply with NFPA 110, Section 8.4.2 and Section 8.4.2.3.

5. The facility failed to perform a fuel quality test annually using approved ASTM standards.

As a result, the facility failed to comply with NFPA 110, section 8.3.8.

6. The facility failed to provide weekly battery electrolyte level inspections, and monthly battery testing and recording of electrolyte specific gravity or battery conductance testing. Note battery conductance testing shall be permitted in lieu of testing the specific gravity when applicable or warranted.

As a result, the facility failed to comply with NFPA 110, Section 8.3.7 and Section 8.3.7.1.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

Based on observations and records provided, the facility failed to properly maintain the automatic emergency generator system.

NFPA 99 section 6.4.4.1.1.3 states maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8.

NFPA 110 (8.3 Maintenance and Operational Testing.)
Section 8.3.1 states that the EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.

Section 8.3.2 states a routine maintenance and operational testing program shall be initiated immediately after the EPSS has passed acceptance tests or after completion of repairs that impact the operational reliability of the system.

Section 8.3.2.1 states the operational test shall be initiated at an ATS and shall include testing of each EPSS component on which maintenance or repair has been performed, including the transfer of each automatic and manual transfer switch to the alternate power source, for a period of not less than 30 minutes under operating temperature.

Section 8.3.3 states a written schedule for routine maintenance and operational testing of the EPSS shall be established.

Section 8.3.4 states a permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.

Section 8.3.4.1 states the permanent record shall include the following:
(1) The date of the maintenance report.
(2) Identification of the servicing personnel.
(3) Notation of any unsatisfactory condition and the corrective
action taken, including parts replaced.
(4) Testing of any repair for the time as recommended by the
manufacturer.

Section 8.3.7 states that storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications.

Section 8.3.7.1 states that 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.

Section 8.3.7.2 states that Defective batteries shall be replaced immediately upon discovery of defects.

Section 8.3.8 (Fuel quality tests) states that a fuel quality test shall be performed at least annually using tests approved by ASTM standards.

Section 8.4.1 states EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

Section 8.4.2 states diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating.

Section 8.4.2.3 states diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.

NFPA 99 section 6.4.4.1.1.4 states the inspection/testing. criteria, conditions, and personnel requirements shall be in accordance with 6.4.4.1.1.4(A) through 6.4.4.1.1.4(C).
(A)* Test Criteria. Generator sets shall be tested 12 times a year, with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8.
(B) Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
(C) Test Personnel. The scheduled tests shall be conducted by competent personnel to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.

Findings Include:

On 08/15/23 and 08/16/23, while reviewing the facility's records as provided, the following was revealed:

The facility is equipped with a 275 kW diesel fueled emergency generator. The generator's name plate indicates that the generator is rated for 275 kW, 343.8 kVA, 208 V / 954 Amps, 3 phase with a 0.8 PF.

The following deficient practice(s) were noted:

1. The facility's most recently documented vendor inspection was a four (4) hour load bank test conducted on 02/11/22. More than 18 months has past since the date of survey and the vendor inspection.

As a result, the facility failed to comply with NFPA 110, Section 8.3.3 which states a written schedule for routine maintenance and operational testing of the EPSS shall be established.

2. The facility's failure to document ampere readings during the following months: August, September, October November and December of 2022, and during February of 2023 substantiates a failure to conduct monthly load testing as required by Section 8.4.1 and Section 8.4.2. Section 8.4.2 states diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes

3. The facility's documented monthly load test data provided: typically noted as 210 volts / 90 Amps; 210 Volts / 87 Amps; 210 Volts / 87 Amps (less than 10 percent of rated nameplate) failed to achieve at least 30% of the rated nameplate on a monthly basis, nor does the documentation record exhaust gas temperatures. In addition, the run time is noted as 0600 - 0630, and not actual hours of run. The analog and digital hours clocks mounted on the unit would note a specific time if actual hours of run were recorded. The facility's Director of Facilities Management stated that the hours clocks were not "accurate."

4. The most recently documented load bank test was conducted on 02/22/22, more than 18 months ago, exceeding the annual requirement.

As a result, the facility failed to comply with NFPA 110, Section 8.4.2 and Section 8.4.2.3.

5. The facility failed to perform a fuel quality test annually using approved ASTM standards.

As a result, the facility failed to comply with NFPA 110, section 8.3.8.

6. The facility failed to provide weekly battery electrolyte level inspections, and monthly battery testing and recording of electrolyte specific gravity or battery conductance testing. Note battery conductance testing shall be permitted in lieu of testing the specific gravity when applicable or warranted.

As a result, the facility failed to comply with NFPA 110, Section 8.3.7 and Section 8.3.7.1.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.

This Standard is not met as evidenced by:

Based on observations and confirmed by staff, the facility failed to ensure that the electrical wiring is in accordance with NFPA 99, (Health Care Facilities Code) 2012 edition. NFPA 99 section 6.3.2.1 states installation shall be in accordance with NFPA 70, (National Electrical Code) 2011 edition.

NFPA 70 section 590.3 has the following time constraints for temporary wiring.
(A) During the Period of Construction. Temporary electric power and lighting installations shall be permitted during
the period of construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or
similar activities.
(B) 90 Days. Temporary electric power and lighting installations shall be permitted for a period not to exceed 90 days for holiday decorative lighting and similar purposes.
(C) Emergencies and Tests. Temporary electric power and lighting installations shall be permitted during emergencies
and for tests, experiments, and developmental work.
(D) Removal. Temporary wiring shall be removed immediately upon completion of construction or purpose for which
the wiring was installed.

THE FINDINGS INCLUDE:

During the morning hours of 08/16/23, electrical extension cords were observed but not limited to the following locations of the basement floor:

1) The Main Electrical Room has an electrical cord supplying power to a fan for cooling the room down.

2) The Kitchen Dish Room has an electrical cord supplying power to a large floor mounted fan.

This deficient practice could affect all patients, staff and visitors within these compartments in the event of the cord over heating creating a fire hazard.

As a result, the facility failed to comply with NFPA 70 section 590.3 regarding the use of extension cords.

This was reviewed with and acknowledged by the facility's Director of Facilities Management and reviewed with the Chief Executive Officer and Director of Facilities Management during the exit conference.