HospitalInspections.org

Based on observation, document review, interview and the Life Safety Code (LSC) complaint investigation findings (ASPEN 1HMQ21, KS00147419) the Critical Access Hospital (CAH) failed to meet applicable provisions of the current LSC by failing to implement a Fire Watch when the CAH did not have a one hour barrier between the current construction and the occupied hospital; a functioning Fire Alarm system or a functioning sprinkler system.

The cumulative effects of the deficient practice resulted in an Immediate Jeopardy (IJ "A situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.") by placing all occupants of the CAH at risk for serious injury, serious harm, serious impairment or death should an emergency occur.

The IJ was removed on 11/05/19 when the CAH initiated a fire watch at 11:55 AM before survey exit..

Findings Include:

During the 50% inspection on 11/05/19 it is observed the CAH did not have a one-hour barrier between the current construction and the occupied hospital, a functioning fire alarm system or a functioning sprinkler system.

National Fire Protection Association (NFPA) Standard: Buildings shall be permitted to be occupied during construction, repair, alterations, or additions only when required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the AHJ [authority having jurisdiction] are in place. 2012 NFPA 101, 4.6.10.1

NFPA Standard: Protection shall be provided to separate an occupied portion of the structure from the area undergoing alteration, construction, or demolition operations when such operations are considered as having a higher level of hazard than the occupied portion of the building. Walls shall have at least a 1-hour fire resistance rating and openings shall have at least a 45-minute fire protection rating. Non-rated walls and openings shall be permitted when an approved automatic sprinkler system is installed. 2012 NFPA 241, 8.6.2


1. At 12:04 PM: Smoke compartment 3 shares walls with the east wing which currently is housing the long-term care patients and does not have proper 1-hour separation. The separation from the smoke compartment 3 and east wing has penetrations throughout and no evidence of type X gypsum board (fire resistant drywall).

2. At 12:08 PM: Smoke compartment 3 is connected to the hospital at the labeled 1-hour smoke barrier between smoke compartment 3 and 1. This smoke barrier does not meet 1-hour separation. The separation does not meet 1-hour due to a 2-foot (ft) x 1 ft penetration and a roughly 3 ft x 6 ft foot section with only one layer of gypsum board located above the drop ceiling. Additionally, the door is a hollow wooden door not rated at 45-minutes, and the door frame is also not rated for 45-minutes. Other small penetrations throughout this separation were noted.

3. At 12:09 PM: The southeast wing connecting to the east wing does not have proper 1-hour separation. The separation is original lath and plaster with penetrations throughout and does not meet any current UL (safety organization) system and no UL system was provided. Additionally, the barrier contains non-fire rated 1-inch (in) x 6 in wood framing.

4. At 12:15 PM: The southeast wing connecting to corridor 105 and corridor 104 does not have proper 1-hour separation. All separation barriers for the southeast wing contain painter's tape which does not meet the finish requirements or the flame or smoke index of healthcare occupancies. Additionally, there are 2 doors in corridor 105 and 1 door in corridor 104 that do not have 45- minute ratings and the door frames are not 45-minute rated.

5. At 12:15 PM: The southeast wing connecting to corridor 105 and corridor 104 and does not have proper 1-hour separation. All separation barriers for the southeast wing contain painter's tape which does not meet the finish requirements or the flame or smoke index of healthcare occupancies. Additionally, there are 2 doors in corridor 105 and 1 door in corridor 104 that do not have 45-minute ratings and the door frames are not 45-minute rated.

6. At 12:18 PM: The southeast wing connecting to the kitchen does not have proper 1-hour separation at the connecting door. Additionally, there is a refrigerator blocking the door leading into the kitchen preventing the door from fully opening. The door does not have a 45-minute rating and the door frame is not 45-minute rated.

7. At 12:23 PM: Smoke compartment 3 shares a wall with west wing which is currently acute care and does not have proper 1-hour separation. The separation from the smoke compartment 3 and west is original lath and plaster and does not meet any current UL system and no UL system was provided.

8. At 2:15 PM: An exit sign is observed in smoke compartment 3 directing occupants into the construction zone of the southeast wing.

Staff K was present and acknowledged findings.

Review of the following NFPA Standard revealed: Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be returned to service. (2012) NFPA 101, 9.6.1.6.


1. At 11:26 PM: The fire alarm panel is observed to be in trouble and silenced. The safety officer, electrical contractor, maintenance director, and construction company could not explain why the panel was in trouble nor why or who silenced it.

Administrator and Maintenance Supervisor were present during the interview and acknowledged the findings.

Review of the following NFPA Standard revealed: Sprinkler System Impairments. Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems. 2012 NFPA 101, 9.7.6

Review of the following NFPA Standard revealed: All preplanned impairments shall be authorized by the impairment coordinator. 2011 NFPA 25, 15.5.1

Review of the following NFPA Standard revealed: Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:

(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b) An approved fire watch.
(c) Establishment of a temporary water supply
(d) Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site. 2011 NFPA 25, 15.5.2

Review of the following NFPA Standard revealed: Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure. When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage. The coordinator shall implement the steps outlined in Section 15.5. 2011 NFPA 25, 15.6.1, 15.6.2 & 15.6.3

Review of the following NFPA Standard revealed: Restoring Systems to Service. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have been implemented:

(1) Any necessary inspections and tests have been conducted to verify that affected systems are operational. The appropriate chapter of this standard shall be consulted for guidance on the type of inspection and test required.
(2) Supervisors have been advised that protection is restored.
(3) The fire department has been advised that protection is restored.
(4) The property owner or designated representative, insurance carrier, alarm company, and other authorities having jurisdiction have been advised that protection is restored.
(5) The impairment tag has been removed 2011 NFPA 25, 15.7

1. At 11:16 AM: Inspection of the smoke compartment 3 under renovation revealed that the drop ceiling had been removed and the space did not have adequate sprinkler protection. The sprinkler heads were not turned upright within and pendants were installed. Additionally, the sprinkler heads in the corridors were found to be removed and the system was capped off.

2. At 12:15 PM: Inspection of the southeast wing under renovation revealed that the drop ceiling had been removed and it is in the same condition as smoke compartment 3. The space did not have adequate sprinkler protection. The sprinkler heads were not turned upright within and pendants were installed. It was also observed that the smoke detection had been removed within southeast wing. Heat detection is not provided.

Staff K was present and acknowledged findings.

(Refer to C0231)

(Refer to LSC Complaint survey findings (ASPEN #1HMQ21, KS00147419) for additional information.

Based on observation, document review, interview and the Life Safety Code (LSC) complaint investigation findings (ASPEN #1HMQ21, KS00147419) the Critical Access Hospital (CAH) failed to meet applicable provisions of the current LSC by failing to implement a Fire Watch when the CAH did not have a one hour barrier between the current construction and the occupied hospital; a functioning Fire Alarm system or a functioning sprinkler system. This deficient practice places all occupants of the CAH at risk for serious injury, serious harm, serious impairment, or death should an emergency occur.

The cumulative effects of the deficient practice resulted in an Immediate Jeopardy (IJ "A situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.") by placing all occupants of the CAH at risk for serious injury, serious harm, serious impairment or death should an emergency occur.

The IJ was removed on 11/05/19 when the CAH initiated a fire watch at 11:55 AM before survey exit.

Findings Include:

During the 50% inspection on 11/05/19 it is observed the CAH did not have a one-hour barrier between the current construction and the occupied hospital, a functioning fire alarm system or a functioning sprinkler system.

National Fire Protection Association (NFPA) Standard: Buildings shall be permitted to be occupied during construction, repair, alterations, or additions only when required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the AHJ [authority having jurisdiction] are in place. 2012 NFPA 101, 4.6.10.1

NFPA Standard: Protection shall be provided to separate an occupied portion of the structure from the area undergoing alteration, construction, or demolition operations when such operations are considered as having a higher level of hazard than the occupied portion of the building. Walls shall have at least a 1-hour fire resistance rating and openings shall have at least a 45-minute fire protection rating. Non-rated walls and openings shall be permitted when an approved automatic sprinkler system is installed. 2012 NFPA 241, 8.6.2

1. At 12:04 PM: Smoke compartment 3 shares walls with the east wing which currently is housing the long-term care patients and does not have proper 1-hour separation. The separation from the smoke compartment 3 and east wing has penetrations throughout and no evidence of type X gypsum board (fire resistant drywall).

2. At 12:08 PM: Smoke compartment 3 is connected to the hospital at the labeled 1-hour smoke barrier between smoke compartment 3 and 1. This smoke barrier does not meet 1-hour separation. The separation does not meet 1-hour due to a 2-foot (ft) x 1 ft penetration and a roughly 3 ft x 6 ft foot section with only one layer of gypsum board located above the drop ceiling. Additionally, the door is a hollow wooden door not rated at 45-minutes, and the door frame is also not rated for 45-minutes. Other small penetrations throughout this separation were noted.

3. At 12:09 PM: The southeast wing connecting to the east wing does not have proper 1-hour separation. The separation is original lath and plaster with penetrations throughout and does not meet any current UL (safety organization) system and no UL system was provided. Additionally, the barrier contains non-fire rated 1-inch (in) x 6 in wood framing.

4. At 12:15 PM: The southeast wing connecting to corridor 105 and corridor 104 does not have proper 1-hour separation. All separation barriers for the southeast wing contain painter's tape which does not meet the finish requirements or the flame or smoke index of healthcare occupancies. Additionally, there are 2 doors in corridor 105 and 1 door in corridor 104 that do not have 45- minute ratings and the door frames are not 45-minute rated.

5. At 12:15 PM: The southeast wing connecting to corridor 105 and corridor 104 and does not have proper 1-hour separation. All separation barriers for the southeast wing contain painter's tape which does not meet the finish requirements or the flame or smoke index of healthcare occupancies. Additionally, there are 2 doors in corridor 105 and 1 door in corridor 104 that do not have 45-minute ratings and the door frames are not 45-minute rated.

6. At 12:18 PM: The southeast wing connecting to the kitchen does not have proper 1-hour separation at the connecting door. Additionally, there is a refrigerator blocking the door leading into the kitchen preventing the door from fully opening. The door does not have a 45-minute rating and the door frame is not 45-minute rated.

7. At 12:23 PM: Smoke compartment 3 shares a wall with west wing which is currently acute care and does not have proper 1-hour separation. The separation from the smoke compartment 3 and west is original lath and plaster and does not meet any current UL system and no UL system was provided.

8. At 2:15 PM: An exit sign is observed in smoke compartment 3 directing occupants into the construction zone of the southeast wing.

Staff K was present and acknowledged findings.

Review of the following NFPA Standard revealed: Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be returned to service. (2012) NFPA 101, 9.6.1.6.

1. At 11:26 PM: The fire alarm panel is observed to be in trouble and silenced. The safety officer, electrical contractor, maintenance director, and construction company could not explain why the panel was in trouble nor why or who silenced it.

Administrator and Maintenance Supervisor were present during the interview and acknowledged the findings.

Review of the following NFPA Standard revealed: Sprinkler System Impairments. Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems. 2012 NFPA 101, 9.7.6

Review of the following NFPA Standard revealed: All preplanned impairments shall be authorized by the impairment coordinator. 2011 NFPA 25, 15.5.1

Review of the following NFPA Standard revealed: Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:

(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b) An approved fire watch.
(c) Establishment of a temporary water supply
(d) Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site. 2011 NFPA 25, 15.5.2

Review of the following NFPA Standard revealed: Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure. When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage. The coordinator shall implement the steps outlined in Section 15.5. 2011 NFPA 25, 15.6.1, 15.6.2 & 15.6.3

Review of the following NFPA Standard revealed: Restoring Systems to Service. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have been implemented:

(1) Any necessary inspections and tests have been conducted to verify that affected systems are operational. The appropriate chapter of this standard shall be consulted for guidance on the type of inspection and test required.
(2) Supervisors have been advised that protection is restored.
(3) The fire department has been advised that protection is restored.
(4) The property owner or designated representative, insurance carrier, alarm company, and other authorities having jurisdiction have been advised that protection is restored.
(5) The impairment tag has been removed 2011 NFPA 25, 15.7

1. At 11:16 AM: Inspection of the smoke compartment 3 under renovation revealed that the drop ceiling had been removed and the space did not have adequate sprinkler protection. The sprinkler heads were not turned upright within and pendants were installed. Additionally, the sprinkler heads in the corridors were found to be removed and the system was capped off.

2. At 12:15 PM: Inspection of the southeast wing under renovation revealed that the drop ceiling had been removed and it is in the same condition as smoke compartment 3. The space did not have adequate sprinkler protection. The sprinkler heads were not turned upright within and pendants were installed. It was also observed that the smoke detection had been removed within southeast wing. Heat detection is not provided.

Staff K was present and acknowledged findings.

(Refer to LSC Complaint survey findings (ASPEN #1HMQ21, KS00147419) for additional information.