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Based on observations and interview, it was determined that the facility failed to ensure one 90-minute fire rated door assembly could automatically close to a latched position.

Findings include:

Observations during tour on 04/13/22 between 1:30 p.m. and 1:45 p.m. with Staff A (Facilities Director) and Staff B (Assistant Facilities Director) revealed the 90-minute fire rated door assembly, located at the top of the stair's in the Main Boiler room, (entrance to the Mechanical Air Handling room) was found in the full open position with a heavy coil of wire propped against the base of the door. The door failed to be able to automatically close to a latched position without assistance.

Interview on 04/13/22 with Staff A and Staff B confirmed the above findings, location and condition's present.

Based on observations and interview, it was determined that the facility failed to ensure one room, exceeding 50 sq. ft., that is being used to store moderate quantities of combustible storage, failed to be equipped with an automatic door closing device.

Findings include:

Observations during tour on 04/14/22 between 9:00 a.m. and 9:30 a.m. with Staff A (Facilities Director) and Staff C (House Keeping Manager) revealed the House Keeping office door, labeled # 5147, located behind the Dietary Suite, failed to be equipped with an automatic door closing device. The office is approximately 140 sq. ft. (10' x 14') and is being used to store moderated quantities of paper goods, hand sanitizer, and multiple types of cleaning products/chemicals.

Interview on 04/14/22 with Staff A and Staff C confirmed the above finding's, location, and quantities of combustible storage within the room.

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

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

11.4 Inspection for Grease Buildup. The entire exhaust system shall be inspected for grease buildup by a properly trained, qualified and certified person(s) acceptable to the authority having jurisdiction and in accordance with table 11.4.
Table 11.4
Volume of Cooking Inspection Frequency
Solid fuel cooking Monthly
24-Hour cooking Quarterly
Moderate volume Semi-annual
Low Volume Annually
11.6.1 Upon inspection, if the exhaust system is found to be contaminated with deposits from grease-laden vapors, the contaminated portions of the exhaust system shall be cleaned by a properly trained, qualified, and certified person(s) acceptable to the AHJ.
11.6.2 Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to remove combustible contaminants prior to the surfaces becoming heavily contaminated with grease or oily sludge.

Based on record review and interview, it was determined that the facility failed to ensure that the Ansul Suppression System received semi-annual inspections and testing of the fire extinguishing system and that documents of the commercial hood cleaning's (semi-annual) were available from 2017 through February 2021.

Findings include:

Record review on 04/13/22 between 8:00 a.m. and 12:00 p.m. with Staff A (Facilities Director) and Staff B (Assistant Facilities Director) revealed the documentation of the suppression inspection and testing dates were as follows:
12/22/21 (8 month's)
04/14/21 (22 month's)
06/10/19 (9 month's)
09/14/18 (5 month's)
05/07/18
No additional records were available for 2017.
Documentation of the required commercial hood cleanings (semi-annual) that were available/conducted on 02/09/22 and 08/30/21 were reviewed, however no previous hood cleaning documents could be located since 2017.

Interview on 04/13/22 and 04/14/22 with Staff A and Staff B confirmed the above findings and available documentation. A new suppression system and commercial exhaust hood were installed in August 2020 (approximately).

NFPA 13 Standard for the Installation of Sprinkler Systems

8.10.6.3 Obstructions That Prevent Sprinkler Discharge from Reaching the Hazard.
8.10.6.3.1 Continuous or non continuous obstructions that interrupt the water discharge in a horizontal plane more than 18" below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8.10.6.3.
8.10.6.3.2 Sprinklers shall be installed under fixed obstructions over 4 feet wide such as stairs and landings.
8.10.6.3.3 Sprinklers shall not be required under obstructions that are not fixed in place.

Based on observations and interview, it was determined that the facility failed to ensure two sprinkler heads' discharge pattern's were not partially blocked by two fixed lighting units.

Findings include:

Based on observations during tour on 04/14/22 between 10:45 a.m. and 11:00 a.m. with Staff A (Facilities Director) and Staff D (Operating Suite Manager) revealed two ceiling mounted light fixture assemblies, located in the PACU (Post Acute Care Unit), are placed within 3" to the side of and 2" below the sprinkler head discharge, effectively blocking the spray pattern for approximately 45% of the sprinkler protection covered area.

Interview on 04/14/22 with Staff A and Staff D confirmed the above findings, locations, and conditions present.

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

Based on record review and interview, it was determined that the facility failed to ensure vendor reported deficiencies and required testing were completed within a timely manner.

Findings include:

Record review on 04/13/22 between 8:00 a.m. and 12:30 p.m. with Staff A (Facilities Director) and Staff B (Assistant Facilities Director) revealed the sprinkler maintenance vendor report dated: 10/23/18, list's a sprinkler system deficiency for the FDC (Fire Department Connection) hydrostatic testing as being due (every 5 years).
The following reports also list the same deficiency (FDC) as being overdue for testing:
01/15/19, 04/25/19, 07/24/19, 10/16/19.
The actual hydrostatic testing documents were completed on 08/19/20 (22 month's as a listed deficiency).

Interview on 04/14/22 with Staff A confirmed the above findings and available documentation.

NFPA 101 Life Safety Code (2012 edition)
8.5 Smoke Barriers
8.5.2.1 Smoke barriers required by this code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof.
8.5.2.2 Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

Based on observations and interview, it was determined that the facility failed to ensure a continuous smoke/fire barrier separation, above the suspended ceiling, in at least three separate locations.

Findings include:

Observations during tour on 04/14/22 between 11:30 a.m. and 1:00 p.m. with Staff A (Facilities Director) revealed the following three locations and conditions where the smoke/fire barriers failed to be sealed to prevent the passage of smoke and the effects from fire:
1. The Mechanical Air handling room, has three unprotected penetrations through the 1-hour fire rated assembly wall, separating the operating suite from the mechanical room:
a. A 2 1/2" sprinkler pipe has had the fire stopping removed creating an opening around the annular space through the barrier wall.
b. There is an 8" square piece of insulation (non-rated) under the air handling ductwork to fill the opening in the barrier wall.
c. There is 2" electrical conduit, from a distribution panel (uncovered) that is open ended creating a penetration through the barrier wall.
2. Above the corridor smoke barrier door, located outside the Lab director's office, has at least four unprotected penetrations through the barrier wall:
a. There is a 1" unprotected hole, with a computer cable passing through the barrier wall.
b. There is a 1 1/2" copper pipe, labeled PROPANE, passing through the barrier wall that is not completely sealed around the pipe.
c. There is a 1" unprotected empty hole through the wall.
d. There is a 2" metal conduit passing through the barrier wall that is not completely sealed around the pipe.
3. Above the suspended ceiling between the corridor and the Operating Suite locker rooms, has at least two unprotected penetrations through the barrier wall:
a. There is a 2 1/2" open unprotected hole (empty) through the barrier wall.
b. There is a small group of unprotected "it"(Internet technologies) cables/conduits passing through the barrier wall.

Interview on 04/14/22 with Staff A confirmed the above findings, locations and conditions that exist.

NFPA 54 National Fuel Gas Code
3.10.1 Valves at Regulators. An accessible gas shut off valve shall be provided upstream of each gas pressure regulator.
3.10.3 Emergency Shutoff Valves. An exterior shutoff valve to permit turning off the gas supply to each building in an emergency shall be provided. The emergency shutoff valves shall be plainly marked as such and their locations posted as required by the AHJ (Authority Having Jurisdiction).

Based on observations and interview, it was determined that the facility failed to ensure the emergency exterior gas line shutoff location was accessible and clearly marked.

Findings include:

Observations during tour on 04/13/22 between 1:40 p.m. and 1:50 p.m. with Staff A (Facilities Director) and Staff B (Assistant Facilities Director) revealed the emergency gas shutoff valve is located on the exterior back wall of the facility, behind the exterior emergency power electrical room stair case. There was a portable rest room partially blocking access and visibility to the shutoff location. An emergency location sign failed to be readily visible.

Interview on 04/13/22 with Staff A and Staff B confirmed the above findings, conditions, and location.

NFPA 99 Health Care Facilities Code (2012 edition)

11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures:
(1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device.
(2) Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects could strike them or fall on them.
(3) Cylinders shall be protected from tampering by unauthorized individuals.
(4) Cylinders,or cylinder valves shall not be repaired, painted, or tampered with.
(5) Safety relief devices in valves or cylinders shall not be tampered with.
(6) Valve outlets clogged with ice shall be thawed with warm water.
(7) A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device.
(8) Sparks and flame shall be kept away from cylinders.
(9) Even if they are to be considered empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them.
(10) Large cylinders (exceeding size E) and larger than 45 kg (100 lbs) shall be transported on a hand hand truck or cart.
(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Based on observations and interview, it was determined that the facility failed to ensure two oxygen cylinders were secured from falling.

Findings include:

Observations during tour on 04/13/22 between 1:50 p.m. and 2:00 p.m. with Staff A (Facilities Director) and Staff B (Assistant Facilities Director) revealed the Medical Gas Manifold/Storage Room, located outside the maintenance department entrance, had two E-sized portable oxygen cylinders found free standing upright in the room (storage rack space available).

Interview on 04/13/22 with Staff A and Staff B confirmed the above findings and location.