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LP-Gas containers or systems of which they are a part shall be protected from damage from vehicles and machinery. NFPA 58 Liquefied Petroleum Gas Code 2011 Edition, Section 6.6.1.2.The facility failed to ensure two (2) of two (2) liquid propane gas containers and above ground piping systems located west of the building were protected from vehicular or machinery damage.Observation determined no physical barriers were in place to protect the containers and copper above-ground piping systems from vehicular or machinery damage from lawn mowing or snow removal equipment.Failure to ensure two (2) of two (2) liquid propane gas containers and the above-ground piping systems were protected from vehicular or machinery damage increases the risk of injury and death by fire.This deficiency affected the entire facility.

1) During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open. 7.2.1.4.3.1

The facility failed to ensure exit access was readily accessible at all times.

Observation determined the following corridor doors opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened.

1) The corridor door to the Janitor Closet by Patient Room #102.
2) The corridor to the Tub/Storage Room by Patient Room #103.
3) The corridor door to the Clean Linen Storage Room by Patient Room #105.

Failure to maintain the means of egress to be available at all times increases the risk of death or injury due to fire.

The deficiency affected three (3) of numerous corridor doors in the means of egress throughout the facility.2) Where the corridor width is at least six (6) feet, non-continuous projections of not more than six (6) inches from the corridor wall, above the handrail height, shall be permitted. 19.2.3.4(2).The facility failed to ensure the corridor width above the handrail was in compliance with these requirements. Observation determined a cabinet housing sprays, paint remover, and paint sprayers was attached to the corridor wall near the west exit.Failure to ensure the minimum width of the means of egress increases the risk of injury and death.This deficiency affected one (1) of two (2) smoke compartments.

The facility failed to maintain the one-hour fire resistive rating at one (1) of one (1) shaft enclosure throughout the west building. 19.3.1.1

The facility failed to ensure the elevator shaft enclosure was of one-hour fire resistance rating. Observation determined the walls inside the elevator shaft enclosure lacked a fire resistance rating since the walls terminated at least three (3) feet below the fluted roof deck.

Failure to protect vertical openings with construction having a fire resistance rating of at least one hour increases the risk of death or injury due to fire.This deficiency affected one (1) of one (1) vertical shaft enclosure.

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. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 19.3.2.1.3.

The facility failed to ensure hazardous areas in fully sprinklered existing health care occupancies are separated from other spaces by smoke-resisting partitions.

Observation determined:1) The door to the Boiler Room failed to self-close and latch into its frame.2) The door to the Maintenance Office which had unsealed openings into an adjacent hazardous area (Physical Therapy Storage Room) had no self-closing device.3) Two (2) of two (2) doors to the Physical Therapy Storage Room used for large amounts of combustible materials lacked self-closing devices.
Failure to ensure hazardous areas were separated from other spaces by smoke-resisting partitions increases the risk of death or injury due to fire.

The deficiency affected three (3) of eleven (11) hazardous areas in the facility.

Smoke detectors must not be located in a direct airflow nor closer than 3 ft. (1 m) from an air supply diffuser or return air opening. 19.3.4.5.1, 9.6.2.10.1.1, NFPA 72 17.7.4.1.

The facility failed to ensure the smoke detection system was in compliance with NFPA 72, National Fire Alarm and Signaling Code.

Observation determined smoke detectors throughout the facility were installed within 3 ft. of an air supply diffuser or air supply vent.

Failure to install the smoke detection system as required increases the risk of death or injury due to fire.

This deficiency affected numerous smoke detectors in the facility. The smoke detection system serves the entire facility.

Heat from a fire stratifies to the suspended ceiling and travels along the suspended ceiling to activate the sprinkler. When suspended ceiling tiles are missing or damaged, it delays the activation of the automatic fire sprinkler system.

The facility failed to ensure the proper position of suspended ceiling tiles in areas protected by the automatic fire sprinkler system. Observation determined two (2) suspended ceiling tiles were missing in the East Shower Room and the sink area adjacent to the Staff Break Room.

Failure to ensure the proper position of suspended ceiling tiles in areas protected by the automatic fire sprinkler system increases the risk of injury and death by fire.

This deficiency affected one (1) of two (2) smoke compartments.

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25.

Record review determined quarterly flow alarm tests of the automatic sprinkler system were not completed as required. Records indicated no flow alarm test was documented for the second quarter of 2016.

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

The deficiency affected the complete automatic sprinkler system, which serves the entire facility.

Fire drills shall be conducted quarterly on each shift to familiarize facility personnel with the signals and emergency action required under varied conditions. 19.7.1.2

The facility failed to conduct fire drills as required.

Fire drill records review determined fire drills were not held at unexpected times under varying conditions.

Three (3) of four (4) Night Shift fire drills (July 2016, October 2016 and January 2017) were completed at 7:00 a.m.

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

The deficiency affected three (3) of twelve (12) drills in the past year.

Building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code. Categories shall be determined by following and documenting a defined risk assessment procedure. NFPA 99 Health Care Facilities Code, 2012 edition, Section 4.1, 4.2.

The facility failed to provide a documented risk assessment of building systems.

Review of documentation and interview of staff determined the facility failed to conduct and document a risk assessment of building systems.

Failure to conduct a risk assessment of building systems increases the risk of injury or death due to fire.

This deficiency affected building systems throughout the entire facility.

A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. NFPA 99 3-4.1.1.15

The facility failed to ensure the emergency generator was in compliance with NFPA 99, Standard for Health Care Facilities.

Observation determined there was no remote annunciator located at a work site readily observable by personnel.

Failure to ensure the emergency generator was in compliance with NFPA 99 increases the risk of death or injury due to fire.

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

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

For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

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

Observation determined there was no remote stop switch for the generator located external to the weatherproof enclosure. The generator was located outside the building.

Failure to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems, increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator for the hospital.

Ref: 2012 NFPA 101 Section 19.2.9.1, 7.9.2.4, 2010 NFPA 110 Section 5.6.5.2(u).

All power strips shall be used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Flexible cords and cables shall not be used for the following:

(1) As a substitute for the fixed wiring of a structure.

(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.

(3) Where run through doorways, windows, or similar openings.

(4) Where attached to building surfaces.

NFPA 70, National Electrical Code, 2010 Edition Section 400-8.

The facility failed to ensure power strips were used with general precautions.Observation determined two (2) of numerous power strips were "daisy-chained" together for laptop computers in Conference Room A in the clinic basement.

Failure to ensure the electrical wiring complies with NFPA 70 for all portions of the building increases the risk of injury and death due to fire.

The deficiency affected one (1) of two (2) smoke compartments.

Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standards for Health Care Facilities. 19.3.2.4.

Electrical devices should be physically protected, such as by use of a protective barrier around the electrical devices, or by location of the electrical device such that it will avoid causing physical damage to the cylinders or containers. NFPA 99, A.5.1.3.3.2(5). In oxygen storage rooms containing more than 300 cu. ft. of gas, all electrical wall fixtures must be physically protected or located at least five (5) feet above the floor.The facility failed to ensure nonflammable medical gas equipment and systems were in compliance with NFPA 99.

Observation determined the Oxygen Storage Room contained over 300 cu. ft. of oxygen and had an electrical wall switch that was unprotected and installed four (4) feet above the floor.

This deficiency affected one (1) of one (1) oxygen storage room in the facility.