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1) The facility failed to ensure communicating openings through a two-hour fire resistant rated occupancy separation wall occur only in corridors. 19.1.1.4.2

Observation determined a doorway through the two-hour fire resistant rated occupancy separation wall from the Activity Room in the hospital to a Storage Room in the administration building.

Failure to ensure communicating openings through two-hour fire resistant rated occupancy separation walls occur only in corridors increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) two-hour fire resistant rated occupancy separation wall in the facility.

2) Fire barriers between a nonconforming occupancy (Administrative Building) and the hospital must be fire barriers having at least a two-hour fire resistance rating with openings protected by self-closing and positive latching 90-minute fire rated doors.

The facility failed to ensure doors in occupancy separation walls were positive latching.

Observation determined:
a) The 90-minute fire rated cross corridor doors in the two-hour fire resistant rated occupancy separation wall did not self-close and latch when tested.
b) Panic hardware was present on the 90-minute fire rated doors and was capable of being dogged in the open position.

Failure to ensure doors in a two-hour fire resistant occupancy separation wall are self-closing and positive latching increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) set of double cross corridor doors through the two hour fire resistant rated occupancy separation.

The facility failed to provide a one-hour fire resistance rated stair enclosure.

Observation determined the walls of the east stair enclosure stopped at the membrane ceiling and were not extended to the roof deck.

Failure to provide one-hour fire resistance rated vertical openings increases the risk of death or injury due to fire.

This deficiency affected one (1) of three (3) vertical shafts in the building.

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

Observation determined:

1) The door to second floor Soiled Linen Room did not have self-closing hardware.

2) The door to the second floor Clean Linen Room did not have self-closing hardware. The Clean Linen Room was 72 square feet.

3) The door to the first floor northeast Storage Room did not self-close and latch. There was also a 1 inch diameter hole through the door.

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

The deficiency affected three (3) of eight (8) hazardous areas in the facility.

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

Observation determined:
1) The facility had not ensured that doors in the means of egress were not locked against egress when the building was occupied.

The stairway doors from the second floor were equipped with access-controlled magnetic locks that required a code to be entered on a key pad to release.

The deficiency affected egress from two (2) of two (2) exits from the second floor.

2) 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. 7.2.1.4.4

Four (4) of numerous doors on the first floor opened outward into the corridor and projected more than 7 inches into the corridor when fully opened.

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


Ref: 2000 NFPA 101 Section 19.2.2.2.4, 7.2.1.6.2

The facility failed to ensure illumination of means of egress was either continuously in operation or capable of automatic operation without manual intervention.

Observation determined:
1) No record was available to verify the battery-pack emergency lights throughout the facility were tested for 90 minutes annually.

This deficiency affected the entire building.

2) The first floor east wing corridor lights were operated by a light switch. There were no battery-pack emergency lights in the corridor.

This deficiency affected one (1) of two (2) means of egress from the first floor.

Failure to ensure illumination throughout the means of egress increases the risk of death or injury due to fire.

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

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. The fire alarm system batteries were load voltage tested by an outside company during the annual inspection on 04/16/2015. Records did not indicate any other load voltage test on the fire alarm system batteries in the past year.

Failure to test and maintain the fire alarm system in accordance with NFPA 72, National Fire Alarm Code, increases the risk of death or injury due to fire.

The deficiency affected one (1) of two (2) required load voltage tests of the batteries in the last year. The fire alarm system serves the entire facility.

Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 table 7-3.2 item 6.d.3.

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

Record review determined:

1) The sprinkler system gauges had not been replaced or calibrated within the last five (5) years.

The deficiency affected one (1) of numerous tests and maintenance items of the automatic sprinkler system. The automatic sprinkler system serves the entire building.

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

There were two (2) holes in the ceiling in the Pharmacy. The holes were approximately 1-foot by 1-foot.

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

1) The facility failed to ensure illumination of means of egress was either continuously in operation or capable of automatic operation without manual intervention.

a) Record review determined no record was available to verify the battery-pack emergency lights throughout the facility were tested for 90 minutes annually or 30 seconds monthly.

b) Five (5) of five (5) battery-pack emergency lights failed when tested.

Failure to maintain illumination throughout the means of egress increases the risk of death or injury due to fire.

This deficiency affected five (5) of five (5) battery-pack emergency light fixtures in the building.

2) The facility failed to inspect fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Observation determined fire extinguishers throughout the facility had not been inspected monthly since the last service date of October 2014.

Failure to ensure portable fire extinguishers comply with NFPA 10 increases the risk of death or injury due to fire.

The deficiency affected four (4) of four (4) portable fire extinguishers in the building.

3) Doors complying with 7.2.1 shall be permitted. 39.2.2.2.1.

Doors shall be operable with not more than one releasing operation. 7.2.1.5.4.

Observation determined the two exits from the north side of the building were equipped with a locking handle and a dead bolt lock requiring two operations to release the door.

Failure to ensure the means of egress is readily accessible at all times increases the risk of death or injury due to fire.

This deficiency affected two (2) of three (3) exits from the building.

4) Existing life safety features obvious to the public, if not required by the Code, must be either maintained or removed. 4.6.12.2

Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. 4.6.12.3

Observation determined the presence of battery operated smoke detectors throughout the facility. No record was available to verify the smoke detectors were being maintained and tested.

Failure to test and maintain life safety features increases the risk of death or injury due to fire.

This deficiency affected the entire building.

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.Maintenance of emergency generator batteries should include checking and recording the value of the specific gravity. NFPA 110, Section A-6-3.6

Record review and interview of maintenance staff determined the batteries in the emergency generator were not tested for specific gravity.

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

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

1) The facility failed to ensure communicating openings through a two-hour fire resistant rated occupancy separation wall occur only in corridors. 19.1.1.4.2

Observation determined a doorway through the two-hour fire resistant rated occupancy separation wall from the Activity Room in the hospital to a Storage Room in the administration building.

Failure to ensure communicating openings through two-hour fire resistant rated occupancy separation walls occur only in corridors increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) two-hour fire resistant rated occupancy separation wall in the facility.

2) Fire barriers between a nonconforming occupancy (Administrative Building) and the hospital must be fire barriers having at least a two-hour fire resistance rating with openings protected by self-closing and positive latching 90-minute fire rated doors.

The facility failed to ensure doors in occupancy separation walls were positive latching.

Observation determined:
a) The 90-minute fire rated cross corridor doors in the two-hour fire resistant rated occupancy separation wall did not self-close and latch when tested.
b) Panic hardware was present on the 90-minute fire rated doors and was capable of being dogged in the open position.

Failure to ensure doors in a two-hour fire resistant occupancy separation wall are self-closing and positive latching increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) set of double cross corridor doors through the two hour fire resistant rated occupancy separation.

The facility failed to provide a one-hour fire resistance rated stair enclosure.

Observation determined the walls of the east stair enclosure stopped at the membrane ceiling and were not extended to the roof deck.

Failure to provide one-hour fire resistance rated vertical openings increases the risk of death or injury due to fire.

This deficiency affected one (1) of three (3) vertical shafts in the building.

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

Observation determined:

1) The door to second floor Soiled Linen Room did not have self-closing hardware.

2) The door to the second floor Clean Linen Room did not have self-closing hardware. The Clean Linen Room was 72 square feet.

3) The door to the first floor northeast Storage Room did not self-close and latch. There was also a 1 inch diameter hole through the door.

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

The deficiency affected three (3) of eight (8) hazardous areas in the facility.

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

Observation determined:
1) The facility had not ensured that doors in the means of egress were not locked against egress when the building was occupied.

The stairway doors from the second floor were equipped with access-controlled magnetic locks that required a code to be entered on a key pad to release.

The deficiency affected egress from two (2) of two (2) exits from the second floor.

2) 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. 7.2.1.4.4

Four (4) of numerous doors on the first floor opened outward into the corridor and projected more than 7 inches into the corridor when fully opened.

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


Ref: 2000 NFPA 101 Section 19.2.2.2.4, 7.2.1.6.2

The facility failed to ensure illumination of means of egress was either continuously in operation or capable of automatic operation without manual intervention.

Observation determined:
1) No record was available to verify the battery-pack emergency lights throughout the facility were tested for 90 minutes annually.

This deficiency affected the entire building.

2) The first floor east wing corridor lights were operated by a light switch. There were no battery-pack emergency lights in the corridor.

This deficiency affected one (1) of two (2) means of egress from the first floor.

Failure to ensure illumination throughout the means of egress increases the risk of death or injury due to fire.

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

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. The fire alarm system batteries were load voltage tested by an outside company during the annual inspection on 04/16/2015. Records did not indicate any other load voltage test on the fire alarm system batteries in the past year.

Failure to test and maintain the fire alarm system in accordance with NFPA 72, National Fire Alarm Code, increases the risk of death or injury due to fire.

The deficiency affected one (1) of two (2) required load voltage tests of the batteries in the last year. The fire alarm system serves the entire facility.

Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 table 7-3.2 item 6.d.3.

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

Record review determined:

1) The sprinkler system gauges had not been replaced or calibrated within the last five (5) years.

The deficiency affected one (1) of numerous tests and maintenance items of the automatic sprinkler system. The automatic sprinkler system serves the entire building.

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

There were two (2) holes in the ceiling in the Pharmacy. The holes were approximately 1-foot by 1-foot.

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

1) The facility failed to ensure illumination of means of egress was either continuously in operation or capable of automatic operation without manual intervention.

a) Record review determined no record was available to verify the battery-pack emergency lights throughout the facility were tested for 90 minutes annually or 30 seconds monthly.

b) Five (5) of five (5) battery-pack emergency lights failed when tested.

Failure to maintain illumination throughout the means of egress increases the risk of death or injury due to fire.

This deficiency affected five (5) of five (5) battery-pack emergency light fixtures in the building.

2) The facility failed to inspect fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Observation determined fire extinguishers throughout the facility had not been inspected monthly since the last service date of October 2014.

Failure to ensure portable fire extinguishers comply with NFPA 10 increases the risk of death or injury due to fire.

The deficiency affected four (4) of four (4) portable fire extinguishers in the building.

3) Doors complying with 7.2.1 shall be permitted. 39.2.2.2.1.

Doors shall be operable with not more than one releasing operation. 7.2.1.5.4.

Observation determined the two exits from the north side of the building were equipped with a locking handle and a dead bolt lock requiring two operations to release the door.

Failure to ensure the means of egress is readily accessible at all times increases the risk of death or injury due to fire.

This deficiency affected two (2) of three (3) exits from the building.

4) Existing life safety features obvious to the public, if not required by the Code, must be either maintained or removed. 4.6.12.2

Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. 4.6.12.3

Observation determined the presence of battery operated smoke detectors throughout the facility. No record was available to verify the smoke detectors were being maintained and tested.

Failure to test and maintain life safety features increases the risk of death or injury due to fire.

This deficiency affected the entire building.

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.Maintenance of emergency generator batteries should include checking and recording the value of the specific gravity. NFPA 110, Section A-6-3.6

Record review and interview of maintenance staff determined the batteries in the emergency generator were not tested for specific gravity.

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

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