HospitalInspections.org

Based on observation and facility staff interview, the facility staff failed to provide a safe building structure when fabricated floor joists had to much additional weight attached to the bottom board of the floor joists than they were designed to hold. This puts all occupants at risk of injury if the floor would collapse. The facility census was 25.

Observation on 1/26/2017 at 8:27 A.M., of the facility basement, showed the engineered "I" floor joists (Manufactured floor joists constructed of oriented strand board and approximately 2 inch by 3 inch boards) hung from metal straps. Observation showed the metal straps wrapped under the ends of the engineered floor joists and ran over the steel I-beam. Observation showed multiple sections of approximately twelve inch chiller pipe containing chilled water suspended from commercial pipe hangers. Observation showed the pipe hangers connected to the engineered floor joists. Observation showed the OSB (Oriented Strand Board) engineered floor joists bearing the hanging weight of the chiller pipe. Observation showed the combined weight of the chiller pipe, floor joists, electrical conduits, sprinkler piping and the building weight from the floor above, the internal load bearing walls of the structure, the roof and all live loads within the structure suspended from the metal straps.

During an interview on 2/09/2017 staff (I) said the chiller pipes were installed before the building was occupied by patients. Additionally, he/she said engineering studies of the building were not available.

NFPA 101, 2012 edition, section 19.1.1.1.3 General. states: "The provisions of Chapter 4, General, shall apply."

NFPA 101, 2012 edition, section 4.2.2 Structural Integrity. Structural integrity shall be maintained for the time needed to evacuate, relocate, or defend in place occupants who are not intimate with the initial fire development."

NFPA 13, Standard For The Installation Of Sprinkler Systems, 2010 edition, Section 9.2.1.3.1 states:
9.2.1.3* Building Structure.
9.2.1.3.1 Unless the requirements of 9.2.1.3.3 apply, sprinkler
piping shall be substantially supported from the building
structure, which must support the added load of the waterfilled
pipe plus a minimum of 250 lb (114 kg) applied at the
point of hanging, except where permitted by 9.2.1.1.2,
9.2.1.3.3, and 9.2.1.4.1.


A.9.2.1.3 The method used to attach the hanger to the structure
and the load placed on the hanger should take into account
any limits imposed by the structure. Design manual information
for pre-engineered structures or other specialty
construction materials should be consulted, if appropriate.
System mains hung to a single beam, truss, or purlin can
affect the structural integrity of the building by introducing
excessive loads not anticipated in the building design. Also,
special conditions such as collateral and concentrated load
limits, type or method of attachment to the structural components,
or location of attachment to the structural components
might need to be observed when hanging system piping in
pre-engineered metal buildings or buildings using other specialty
structural components such as composite wood joists or
combination wood and tubular metal joists.
The building structure is only required to handle the weight
of the water-filled pipe and components, while the hangers are
required to handle 5 times the weight of the water-filled pipe. In
addition, a safety factor load of 250 lb (114 kg) is added in both
cases. The difference in requirements has to do with the different
ways that loads are calculated and safety factors are applied.
When sprinkler system loads are given to structural engineers
for calculation of the structural elements in the building, they
apply their own safety factors in order to determine what structural
members and hanging locations will be acceptable.
In contrast, when sprinkler system loads are calculated for
the hangers themselves, there is no explicit safety factor, so
NFPA 13 mandates a safety factor of 5 times the weight of the
pipe.

Based on observation, and facility staff interview, facility staff failed to ensure sections of the health care occupancy was separated from non healthcare occupancies by a two hour fire resistant barrier and complete sprinkler coverage provided by a NFPA 13 compliant sprinkler system. Occupancy separation walls without a two hour fire resistance rating reduces the hospital construction standard to Type V (000), a prohibited construction standard for hospitals. The facility census was 25.

Observation on 1/26/2017 showed the building use divided into outpatient therapy services, medical office use and inpatient behavioral healthcare.

Observation on 1/26/2017 showed the following at the south end of structure containing outpatient psych services and medical offices:

1. Observations of the 2 hour occupancy separation (Medical office building and Hospital building) in the attic above the classroom and locker room on the hospital side did not show either an ember break or rated roof sheathing or rated B or C roof covering. (Please refer to NFPA 221,2012 edition, High Challenge Fire Walls, Fire Walls, And Fire Barrier Walls, Section 6.6.4 for additional information.)

2. Observation of the corridor occupancy 2 hour separation barrier doors between the center section of the building and the south end of the structure showed the six panel doors contained glass panels without a rating or were wire backed glass. Observation showed the double door frame was constructed of wood.

3. Observations of the 2 hour occupancy separation in the attic above the medical offices on the medical office side of the wall did not show either an ember break or rated roof sheathing or rated B or C roof covering. (Please refer to NFPA 221,2012 edition, High Challenge Fire Walls, Fire Walls, And Fire Barrier Walls, Section 6.6.4 for additional information.)

4. Observation showed the facility did not contain a complete sprinkler system per NFPA 13 requirements.

During an interview on 2/09/2017 staff (I) said the north fire wall was installed before the building was occupied with patients and the south fire wall was completed after patient occupancy. Additionally, he/she said an engineering review of the building was unavailable.

NFPA 101, 2012 edition, section 19.1.3.3 states:

19.1.3.3* Sections of health care facilities shall be permitted to
be classified as other occupancies, provided that they meet all
of the following conditions:
(1) They are not intended to provide services simultaneously
for four or more inpatients for purposes of housing, treatment,
or customary access by inpatients incapable of self preservation.
(2) They are separated from areas of health care occupancies
by construction having a minimum 2-hour fire resistance
rating in accordance with Chapter 8.
(3) For other than previously approved occupancy separation
arrangements, the entire building is protected throughout
by an approved, supervised automatic sprinkler system
in accordance with Section 9.7.


Please refer to K351 for additional information regarding the sprinkler system.

Based on observation and facility staff interview, the building does not meet the building construction type to be a hospital, the psychiatric unit is in a type V (000) unprotected construction, which is not allowed to be used as a hospital. This type of construction puts all patients, staff and visitors at a higher risk of injury or death from a fire. The facility applied intumescent paint to the structural wood frame of the building to achieve a one hour fire resistance rating. The paint was intended to make the structure compliant with a Type V (III) construction requirement per NFPA 101, 2000 edition, new construction. Unpainted wood frame sections, compromised barrier separations and missing required sprinkler coverage reduces the intended construction standard from a Type V(III) protected wood frame to a Type V (000) unprotected wood frame.

The patient census was 25.


A. Basement
1. Observations of the basement showed the engineered floor joists were not completely painted with intumescent paint, exposing bare OSB and wood in the basement.

B. Center section of the structure:

1. Observations of the 2 hour occupancy separation (Medical office building and Hospital building) in the attic above the classroom and locker room on the center section of the building side did not show either an ember break or rated roof sheathing or rated B or C roof covering. Required two hour rated separation walls without a two hour fire resistance rating reduces the hospital construction standard to Type V (000), a prohibited construction standard for hospitals. (Please refer to NFPA 221,2012 edition, High Challenge Fire Walls, Fire Walls, And Fire Barrier Walls, Section 6.6.4 for additional information.)

2. Observation of the center section of the structure in the attic space showed the attic space between the Medical Library and the exterior wall of the Recreational Therapy room not accessible for inspection. Observations could not be made to determine if the attic contained sprinkler coverage and intumescent paint on the wood frame in the attic.

3. Observation in the attic space above the Dining Room showed a three feet by three feet opening extending from the attic space thru to the interstitial space between the unrated lay in ceiling and the missing sheetrock barrier which protects the wood frame of the building. Additional observation in the attic space did not show intumescent paint on the ceiling joists in the attic from the Medical Library east wall extending through the structure to the exterior west wall of the kitchen.

4. Observation of the interstitial space between the lay in ceiling and the missing sheetrock barrier above the Medical Library east wall extending through the structure to the interior west wall of the kitchen showed the unprotected (not painted with intumescent paint) wood frame of the structure.

5. Observation of the one hour barrier wall in the attic between the dining room and kitchen showed an exposed, unpainted (not painted with intumescent paint) board supporting the barrier wall frame extending the length of the barrier wall.

6. Observation in the attic space above the dining room and kitchen showed an approximately three feet by three feet opening in the false roof deck exposing the actual roof sheathing constructed of oriented strand board. Observation showed the roof sheathing and building frame not painted with intumescent paint.

7. Observation of the attic space above the computer room extending through the structure to the Medical Director's office showed the unprotected, (not painted with intumescent paint) wood frame of the structure.

8. Observation of the sprinklers in the attic space showed sprinklers centered in the attic space at the peak of the roof in the compartment above the Medical Library, dining room and kitchen. Observation showed approximately 30 feet on each side (north & south) of the sprinklers extending to the eaves without additional sprinkler coverage. Observation showed the space contained a large quantity of building frame studs forming vertical and horizontal blockages of the sprinkler heads.

9. Observation of the corridor occupancy 2 hour separation barrier doors between the center section of the building and the south end of the structure showed the six panel doors contained glass panels without a rating or were wire backed glass. Observation showed the double door frame was constructed of wood. Required one and one half hours rated doors without a one and one half hours fire resistance rating reduces the hospital construction standard to Type V (000), a prohibited construction standard for hospitals.


C. South end of structure containing outpatient psych services and medical offices.

1. Observations of the 2 hour occupancy separation in the attic above the offices on the south section of the building side did not show either an ember break or rated roof sheathing or rated B or C roof covering. Required two hour rated separation walls without a two hour fire resistance rating reduces the hospital construction standard to Type V (000), a prohibited construction standard for hospitals. (Please refer to NFPA 221,2012 edition, High Challenge Fire Walls, Fire Walls, And Fire Barrier Walls, Section 6.6.4 for additional information.) The reduced construction Type V (000) of the medical office section of the structure reduced the construction standard of Type V (III) in the Hospital section of the structure due to the compromised occupancy separation barrier.

2. Observation of the cross corridor doors in the 2 hour occupancy barrier wall between the center section of the building and the south end of the structure showed the six panel doors contained glass panels without a rating. Observation showed the double door frame was constructed of wood. Required one and one half hours rated doors without a one and one half hours fire resistance rating reduces the hospital construction standard to Type V (000), a prohibited construction standard for hospitals.

D. Patient Wing (North end of structure)

1. Observations of the 2 hour separation between the Patient Hall in the attic above the dining room and Medical Library on the center section of the building side did not show either an ember break or rated roof sheathing or rated B or C roof covering. Required two hour rated separation walls without a two hour fire resistance rating reduces the hospital construction standard to Type V (000), a prohibited construction standard for hospitals. (Please refer to NFPA 221,2012 edition, High Challenge Fire Walls, Fire Walls, And Fire Barrier Walls, Section 6.6.4 for additional information.) Observation on the Patient Hall side of the 2 hour barrier was obstructed by ductwork.

2. Observations above the lay in ceiling in the Exam room, stairwell alcove, staff observation room and interview consultation room showed the Patient Hall contained unprotected (not painted with intumescent paint) wood building frame.

3. Observations in the attic above the men's and women's sleeping wing showed incomplete intumescent paint coverage. Observation showed the wood building frame in the compartmented space above the seclusion room was not painted. Observation showed the rated attic access door in a one hour rated wall between the attic space above the men's and women's sleeping wing and above the seclusion room did not have a self closure. Required one hour rated doors without a one hour fire resistance rating reduces the hospital construction standard to Type V (000), a prohibited construction standard for hospitals.


During an interview on 2/09/2017 staff (I) said a subcontracted Life Safety Consultant specified intumescent paint needed to be applied in the attic space over the men's and women's sleeping areas only. Additionally, he/she said the painting was done by a contracted painter. Staff (I) said the sprinkler system in the building was original to the building before the hospital occupied the building with patients. Additionally, he/she said no alterations were made to the sprinkler system since the building has been occupied with patients.

Based on observation the facility failed to ensure five of five patient exit corridors in the hospital's in-patient care unit serving as exit access were 8 feet in width. This failure puts all patients, staff and visitors at risk of injury or death from fire by having the corridors reduced in size to exit the building.
The patient census was 25.

Observation on 01/26/17, during the building tour, showed the exit corridor to the patient hall, the three exits out of the men's and women's unit was 7 ft 6 inches in width. The exit corridor where the patient therapy room was located was 6 ft wide.

Based on observation, record review and facility staff interview, facility staff failed to provide the required complete sprinkler system per NFPA 13 requirements and complete smoke detection system in compliance with NFPA 72 to allow special locking arrangements in the building. The facility census was 25.

Observation on 1/26/2017, during the facility tour, showed every door within the hospital section of the structure equipped with a card activated access controlled lock.

Observation did not show complete smoke detection in the following locations:
-Men's and women's locker rooms,
-Both activity room storage closets and the office supply closet

-Observation on 1/26/2017, during the facility tour, did not show complete sprinkler coverage in the attic.

-Record review showed the plans for the sprinkler system were not available.

-Observation showed all staff did not have key cards that release the locks.

During an interview on 1/26/2017, staff (I) said he/she did not have a key card that released the door locks.





19.2.2.2.5.1* Door-locking arrangements shall be permitted
where the clinical needs of patients require specialized security
measures or where patients pose a security threat, provided
that staff can readily unlock doors at all times in accordance
with 19.2.2.2.6.

19.2.2.2.5.2* Door-locking arrangements shall be permitted
where patient special needs require specialized protective measures
for their safety, provided that all of the following are met:
(1) Staff can readily unlock doors at all times in accordance
with 19.2.2.2.6.
(2) A total (complete) smoke detection system is provided
throughout the locked space in accordance with 9.6.2.9, or
locked doors can be remotely unlocked at an approved, constantly
attended location within the locked space.
(3)*The building is protected throughout by an approved,
supervised automatic sprinkler system in accordance with
19.3.5.1.
(4) The locks are electrical locks that fail safely so as to release
upon loss of power to the device.
(5) The locks release by independent activation of each of the
following:
(a) Activation of the smoke detection system required by
19.2.2.2.5.2(2)
(b) Waterflow in the automatic sprinkler system required
by 19.2.2.2.5.2(3)

19.2.2.2.6 Doors that are located in the means of egress and are
permitted to be locked under other provisions of 19.2.2.2.5 shall
comply with all of the following:
(1) Provisions shall be made for the rapid removal of occupants
by means of one of the following:
(a) Remote control of locks
(b) Keying of all locks to keys carried by staff at all times
(c) Other such reliable means available to the staff at all
times
(2) Only one locking device shall be permitted on each door.
(3) More than one lock shall be permitted on each door, subject
to approval of the authority having jurisdiction.

Based on observation, record review and facility staff interview, facility staff failed to provide self closing devices on all doors located in smoke barriers and hazardous areas. The facility census was 25.

Observation on 1/26/2017, during the facility tour, showed the following:

-Compartment access hatch in the one hour wall located in the attic between the women's sleeping wing and the space above the seclusion room did not contain a self closing device

-The door between the break room hall and the clean storage room did not have a self closing device. Additional observation showed the room measured approximately 20 feet by 20 feet, contained a large quantity of combustible storage including linens, miscellaneous storage, 19 portable oxygen tanks, carpeted floor and one non rated plastic 23 gallon trash receptacle containing paper waste.

-Observation showed the building did not contain a complete sprinkler system per NFPA 13.

-Observation showed the building did not contain complete smoke detector coverage.

During an interview on 2/09/2017 staff (I) said a contracted Life Safety Consultant evaluated the building and notified hospital staff with a list of doors requiring self closures and other work which needed to be done to meet code requirements.

Refer to K351 for additional information regarding the required complete sprinkler system.

Refer to K341, K342 and K345 for additional information regarding the building fire alarm system. Additionally, refer to The National Electric Code and NFPA 72, National Fire Alarm and Signaling Code for additional smoke detector requirements.

NFPA 101, 2012 edition section 19.2.2.2.7 states:


19.2.2.2.7* 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.

Based on observation the facility failed to ensure five of five patient exit corridors in the hospital's in-patient care unit serving as exit access were 8 feet in width. This failure puts all patients, staff and visitors at risk of injury or death from fire by having the corridors reduced in size to exit the building.
The patient census was 25.

Observation on 01/26/17, during the building tour, showed the exit corridor to the patient hall, the three exits out of the men's and women's unit was 7 ft 6 inches in width. The exit corridor where the patient therapy room was located was 6 ft wide.

Based on observation the facility failed to ensure four of six patient exit doors had a opening clear width of 41.5 inches wide. Failure to provide 41.5 inch clear width opening puts all patients, staff and visitors at risk of injury or death from a fire by restricting the access to the doors to exit the building.

The patient census was 25.

Observation on 01/26/17, during the building tour, showed the exit doors in patient care unit had three exit doors that were 36 inches wide and the exit door out of the therapy room exit corridor was 32 inches wide.

Based on observation and facility staff interview, the facility staff failed to ensure all designated exits were marked by exit signs. The facility census was 25.

On 1/25/ 017, During the initial tour, observation showed in the connecting corridor between the Patient unit and the cafeteria there were no lighted exit signs on both ends of the corridor to direct patients, staff and visitors showing the direction to get to an outside exit.

During an interview on 2/09/2017 staff (I) said he/she was unaware of the missing exit signs.

7.10.1.5 Exit Access.
7.10.1.5.1 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.

Based on observation and facility staff interview, facility staff failed to enclose all vertical openings between the floor and the roof of the structure. Vertical openings between the occupied floor and the attic space continuing through the false roof deck which are unprotected allows the passage of smoke and products of combustion to pass through the structure, increasing the probability of fire propagation. This violation in conjunction with an unprotected wood frame, lack of code compliant smoke and fire barrier walls and lack of complete sprinkler coverage within the same attic space increases the risk of fire propagation in the event of a fire. The unprotected vertical openings provide a passage for air to fuel a fire within the interstitial space between the unrated lay in ceiling and the missing sheetrock barrier which protects the wood frame of the building and provides a passage for a fire to propagate in the attic space. The facility census was 25.

1. Observation in the attic space above the Dining Room showed a three feet by three feet vertical opening extending from the attic space thru to the interstitial space between the unrated lay in ceiling and the missing sheetrock barrier which protects the wood frame of the building.

2. Observation in the attic space above the dining room and kitchen showed an approximately three feet by three feet vertical opening in the false roof deck exposing the actual roof sheathing constructed of oriented strand board.

3. Observation in the attic space above the dining room and kitchen showed an approximately three inch pipe extending from below the attic space through the false roof deck. Observation did not show the pipe was sealed where it penetrated the false roof.

4. Observation in the attic space above the dining room and kitchen showed a gap of approximately eight inches between the metal duct shaft equipped with HVAC controls penetrating the ceiling to attic space barrier and the false roof deck.


During an interview on 2/09/2017 staff (I) said a contracted Life Safety Consultant evaluated the building and repairs were conducted by subcontractors. Hospital staff were unaware of problems with the building. Additionally, he/she said the building evaluation and repairs were intended to temporarily meet code requirements so the building could be used.

19.3 Protection.
19.3.1 Protection of Vertical Openings. Any vertical opening
shall be enclosed or protected in accordance with Section 8.6,
unless otherwise modified by 19.3.1.1 through 19.3.1.8.

19.3.1.1 Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.

8.6.2* Continuity. Openings through floors shall be enclosed
with fire barrier walls, shall be continuous from floor to floor,
or floor to roof, and shall be protected as appropriate for the
fire resistance rating of the barrier.

Based on observation, facility staff interview and record review, facility staff failed to enclose hazardous areas with smoke barriers. The facility census was 25.

Observation on 1/26/2017, during the facility tour, showed the following:

-Door between the Break room hall and the clean storage room did not have a self closing device. Additional observation showed the room measured approximately 20 feet by 20 feet, contained a large quantity of combustible storage including linens, miscellaneous storage, 19 portable oxygen tanks, carpeted floor and one non rated plastic 23 gallon trash receptacle containing paper waste.

-Two roll down pass thru windows in the one hour separation wall between the kitchen and dining room. Additional observation showed the roll down windows in the one hour wall not connected to the fire alarm.

-Record review of the annual fire alarm inspections for 2014, 2015 and 2016 did not show inspections of the roll down windows in the kitchen 1 hour barrier wall.

-Observation showed the building did not contain a complete sprinkler system per NFPA 13 requirements.

-Observation showed the kitchen door in the one hour wall did not have a rating label.

-Observation of the one hour barrier wall in the attic between the dining room and kitchen showed an exposed, unpainted (not painted with intumescent paint) board supporting the barrier wall frame extending the length of the barrier wall.

During an interview on 2/09/2017 staff (I) said a contracted Life Safety Consultant evaluated the building and repairs were conducted by subcontractors to meet code requirements. Additionally, he/she said the building evaluation and repairs were intended to temporarily meet code requirements so the building could be used.

Based on observation, record review and facility staff interview, the facility staff did not ensure interior ceiling and wall finishes met Class A or Class B flame spread requirements. The facility census was 25.

Observations on 1/25 & 26/2017, during the facility tour, showed all patient accessible and designated exit corridors had wood board wainscoting on the corridor walls. Observation showed a wood ceiling in the dining room, Men's sleeping Unit and the Women's sleeping unit.

Observation showed the building sprinkler system did not meet NFPA 13, Standard For The Installation Of Sprinkler Systems, 2010 edition installation requirements.

Staff (H) confirmed the observations. Records of third party flame spread testing for the various wood ceilings and wall coverings were unavailable. Record review showed application records only.


19.3.3.2* Interior Wall and Ceiling Finish. Existing interior
wall and ceiling finish materials complying with Section 10.2
shall be permitted to be Class A or Class B.

Based on facility staff interview and the lack of records to be reviewed, facility staff failed to ensure the fire alarm system was installed per NFPA 70, The National Electric Code and NFPA 72, National Fire Alarm and Signaling Code. The facility census was 25.

During an interview on 2/09/2017, Staff (I) stated the fire alarm design and installation records were not available. Additionally, he/she said the fire alarm system was installed on an unknown date in the building before the hospital took over the building and occupied it with patients.

19.3.4.1 General. Health care occupancies shall be provided
with a fire alarm system in accordance with Section 9.6.

Refer to NFPA 72, National Fire Alarm and Signaling Code sections 14.4.1.1 and 14.4.1.2 for additional testing information.

Based on observation, facility staff interview and record review, facility staff failed to ensure the fire alarm system would be initiated by activation of the sprinkler system. The facility census was 25.

Record review of the fire alarm inspections for 2014, 2015 and 2016 did not show a connection function test of the sprinkler system to fire alarm.

Record review of the fire alarm inspections for 2014, 2015 and 2016 did not show a connection function test of the kitchen range hood system to fire alarm.

During an interview on 1/26/2017 staff (I) said he/she believed the fire alarm inspection company did the inspections per code requirements.

19.3.4.2* Initiation.
19.3.4.2.1 Initiation of the required fire alarm systems shall
be by manual means in accordance with 9.6.2 and by means of
any required sprinkler system waterflow alarms, detection devices,
or detection systems, unless otherwise permitted by
19.3.4.2.2 through 19.3.4.2.4.

Based on nationally recognized standards and observation the facility failed to ensure that elevator lobby doors designed to shut with activation of the fire alarm system would operate as intended for two of five doors tested. One fire rated double door did not close when released from the hold open mechanism.

1. Chapter 7.2.13.3 of the 2012 edition of the Life Safety Code published by the National Fire Protection Association showed that every floor served by the elevator shall have an elevator lobby. Barriers forming the elevator lobby shall have a minimum 1-hour fire resistance rating and shall be arranged as a smoke barrier in accordance with section 8.5.

2. Observation during tour on 01/25-26/17 showed elevator lobbies and stairs used a powered curtain door to provide protection to the areas and had a one hour rating. The curtain door could be tested with a key to initiate closing as they are designed to operate when the fire alarm activated.

3. Observation on 01/25/17 showed that a curtain door identified as being in area 5B did not fully close when tested with the key. Observation on 01/26/17 of the curtain door identified as being in area 3C did not close the last two feet when tested with a key.

4. Observation on 01/25/17 of the double door in area 5A showed the doors did not shut completely when released from the magnetic hold open. This was a double set of wooden doors in a corridor and rated fire separation. A pressure difference from the heating/cooling system in the two areas did not allow the door to close fully.

Based on record review and facility staff interview, facility staff did not ensure all devices connected to the fire alarm system were inspected and tested per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. The facility census was 25.

Record review of the annual fire alarm inspections for 2014, 2015 and 2016 did not show connection function tests for the following devices:

-Sprinkler system tamper and flow alarms
-fire and smoke dampers
-Range hood

Record review of the annual fire alarm inspections for 2014, 2015 and 2016 did not show smoke detector sensitivity testing for the facility smoke detectors.

Record review of the Faraday MPC-6000 specifications information catalog sheet did not show the fire alarm control panel manufactured to be a self monitoring system capable of conducting smoke detector sensitivity monitoring.

Record review of the fire alarm inspection reports for 2014, 2015 and 2016 showed a note stating: "Trouble conditions not being monitored".

During an interview on 1/26/2017 at 2:45 P.M., staff (I) said he/she believed the fire alarm inspection company did the inspections per code requirements.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, Table 14.3.1, Table 14.4.2.2, Table 14.4.5, sections 14.4.5, 14.4.5.3.1 through section 14.4.5.4 for additional testing information. Refer to section 10.12 for trouble signal information.

Based on observation, record review and facility staff interview, facility staff failed to ensure the building sprinkler system met NFPA 13, Standard For The Installation Of Sprinkler Systems, 2010 edition installation requirements. The facility census was 25.

Observation on 1/26/2017, during the facility tour, showed the following:

1. Observation of the attic space above the Break Room hall and storage room showed three horizontal sprinkler arms protruding from the one hour barrier wall. Observation showed the three sprinkler arms extending three feet horizontally without a pipe hanger. Observation showed three sprinkler sprig lines (vertical sprinkler pipe) connected to the three horizontal arms extended approximately six feet vertically without pipe hangars to brace for lateral movement.

2. Observation of the attic space above the Break Room hall and storage room showed one painted sprinkler head on a sprig line in the center of the attic space.

3. Observations in the basement showed four of seven sprinkler heads blocked by electrical conduit, sprinkler piping and chiller pipe hangers in the basement area containing the generator automatic transfer switches.

4. Observation showed the basement access stairwell contained two ordinary temperature quick response sprinkler heads and one, intermediate temperature quick response sprinkler head in the same compartmented space.

5. Observation of the spare sprinkler head storage box showed it contained four intermediate temperature quick response sprinkler heads, one ordinary temperature quick response side discharge sprinkler head and one brass side discharge unmarked sprinkler head. The total number, temperature ratings and type of sprinkler heads installed in the building were unknown due to unavailable sprinkler plans or installation records for the sprinkler system.

6. Observation of the center section of the structure in the attic space between the Medical Library and the exterior wall of the Recreational Therapy room not accessible for inspection. Observations could not be made to determine if the attic contained sprinkler coverage.

7. Observation of the sprinklers in the attic space showed sprinklers centered in the attic space at the peak of the roof in the compartment above the Medical Library, dining room and kitchen. Observation showed approximately 30 feet on each side (north & south) of the sprinklers extending to the eaves without additional sprinkler coverage. Observation showed the space contained a large quantity of building frame studs forming vertical and horizontal blockages of the sprinkler heads.

Record review did not show approved sprinkler plans or installation records for the sprinkler system.

During an interview on 2/09/2017 staff (I) said sprinkler system plans were unavailable. Additionally, he/she said the sprinkler system was in the building prior to the hospital occupying the building with patients and no modifications or additions to the system have been made to date. He/she did not know if there were sprinklers installed in the attic space between the Medical Library and the exterior wall of the Recreational Therapy room

Refer to NFPA 13, 2010 edition, Chapter 8 for sprinkler obstruction information, section 6.2.6.2 for painting information, section 6.2.9 for spare sprinkler head requirements and table 6.2.5.1 for sprinkler head temperature rating requirements. Refer to sections 9.2.3.5.1 and 9.2.3.7 for pipe hanger requirements.

Based on record review and facility staff interview, the facility staff failed to ensure the sprinkler supervisory alarms were installed and monitored per NFPA 72, National Fire Alarm and Signaling Code, 2010 edition. The facility census was 25.

Record review of the annual fire alarm inspections for 2014, 2015 and 2016 did not show the sprinkler system supervisory alarms listed as function tested with the fire alarm.

Record review did not show fire alarm plans or sprinkler plans available for review.

Record review did not show annual sprinkler system inspections available for review.

During an interview on 1/26/2017 at 2:45 P.M., staff (I) said he/she believed the fire alarm inspection company did the inspections per code requirements.

Based on staff interview and record review, facility staff failed to inspect the wet & dry sprinkler systems per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. The facility census was 25.

Record review on 1/26/2017 did not show the following inspections:

-annual inspection for the wet sprinkler system for any year

-annual inspection for the dry sprinkler system for any year

- 3 year dry system full trip test

- 5 year backflow/check valve inspections

-5 year internal pipe & gauges

During an interview on 1/26/2017 at 2:45 P.M., staff (I) stated he/she believed the hospital staff conducted the sprinkler inspections per code requirements.

Refer to NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5, 13 and 14 for additional information.

Based on record review and observation the facility failed to ensure that all patient room doors closed and latched securely for 11 of the doors tested in the facility. A majority of the patient doors were tested for latching in the facility.

1. Record review showed the facility had a system for testing the operation of doors in the facility.

2. Observation during tour of the facility on 01/25-26/17 showed the majority of the patient rooms had a wooden double door with one leaf which provided additional clearance when needed and latched during normal use and a second leaf used for typical room egress. Specialty units of the facility had a sliding glass door for egress.

3. Patient room doors were closed during tour to ensure they latched. Wooden double doors to rooms 3003, 3019, 6002, 6004, 6017, 6104, 7005, 7117, and 7123 did not latch securely or stay closed. Sliding glass doors to rooms 3013 and 3122 did not latch when closed.

Based on observation the facility staff failed to provide corridor doors of substantial construction. The facility census was 25.

Observations on 1/26/2017, during the facility tour, showed the corridor doors consisted of six panel decorative doors mounted in door frames constructed of wood.

Observation of the building showed it did not contain a complete sprinkler system in compliance with NFPA 13.

Based on observation and facility staff interview, the facility staff failed to ensure glass panels in smoke barrier doors had fire rated glazing or were constructed of wire backed glass. The census was 25.

Observation of the corridor occupancy 2 hour separation barrier doors between the center section of the building and the south end of the structure showed the six panel doors contained glass panels without a rating or were wire backed glass. Observation showed the double door frame was constructed of wood.

During an interview on 2/09/2017 staff (I) said hospital staff was told by a contracted Life Safety Consultant the six panel doors, door frame and glass panel met code requirements.

NFPA 101, Life Safety Code, 2012 edition section 19.3.7.6 states:

19.3.7.6.2 Doors shall be permitted to have fixed fire window
assemblies in accordance with Section 8.5.

Based on observation and facility staff interview, facility staff failed to ensure electrical equipment & wiring installations met NFPA 70, National Electrical Code, 2011 edition. The census was 25.

Observations on 1/26/2017, during the facility tour, showed the following:

-Metal junction box containing 4 outlets hanging by its own wiring and cable sheathing below a circuit breaker panel in the basement

-Open junction box above the range hood behind the access panel exposing wires and connections in the kitchen

-Observation in the kitchen of the oven range, flat top grill, convection oven and steamer, located under the range hood, showed four electric shut off switches mounted to the wall behind each cooking appliance exceeding three feet of clear space to reach the shutoff switches.

-Large quantity of cardboard boxes piled against the circuit breaker boxes in the computer room.

During an interview on 2/09/2017, Staff (I) stated the electrical shutoff switches in the kitchen were installed on an unknown date in the building before the hospital took over the building and occupied it with patients. Additionally, he/she said he/she was unaware of the hanging junction box, open junction box and storage clearance.


Refer to NFPA 70, National Electrical Code, 2011 edition, Article 110.26 for additional information regarding clear working space, Article 300 for covered junction boxes and mounting of junction/receptacle boxes.

Based on record review and interview the facility failed to ensure that drills were conducted quarterly for all staff, staff were familiar with procedures and an assessment of the effectiveness of the drills was completed for each drill.

1. Review of the facility's record for fire drills conducted for 2016 showed the areas and shifts for which fire drills had been conducted. Eight of the 14 areas noted for the main hospital were indicated as having three shifts of staff covering a 24 hour period.
The report for the eight areas with three shifts of personnel showed:
- First quarter of 2016 no drill on third shift was noted as having been done for the eight areas;
- Second quarter of 2016 showed four areas did not have a third shift fire drill.
- Third quarter of 2016 showed two areas that did not get a second shift drill and two with no third shift drill;
- Fourth quarter of 2016 showed two areas with no second quarter drill.

2. Review of the evaluation forms completed for drills showed one staff had been evaluated for the drills effectiveness.
Note: the fire drill evaluation form showed space for one staff member to be evaluated for drill effectiveness for each drill completed. All drills indicated as conducted did not have an evaluation form completed for each drill.

3. During an interview on 01/26/17 at 2:05 PM, Staff D, Manager of Safety and Security, stated that the format used for documenting drills had changed since last year. Security staff implemented the drills and documented the scenario for the drill and interviewed one staff person for each drill in 2016.
Staff D noted on the form for fire drills conducted which floors had all three shifts of staff on duty or which areas had the need for three drills per quarter.

4. During interview on 01/26/17 at approximately 8:45 AM, two unidentified staff working in the kitchen were asked to locate the manual pull for the hood extinguishment system. Both staff were observed working under hood #5. Both staff responded that they did not know where the manual pull was located. Observation during this interview showed that there were five distinct manual pull stations for hood extinguishment systems in the kitchen area.

Based on record review and interview the facility failed to ensure that all building systems had been assigned a risk assessment category and documented.

1. Review of the facility documents for fire safety, building system tests, and policies showed no assessment of the which systems were critical for patient safety.

2. During an interview on 01/26/17 at 3:20 PM, Staff D, Manager of Safety and Security, stated that an assessment which documented a risk assessment category for building systems had not been done.

Based on observation and facility staff interview, the facility staff failed to ensure extension cords were not used permanently. The facility census was 25.

Observation on 1/26/2017, during the facility tour, showed an extension cord penetrating the one hour rated wall between the attic spaces above the seclusion room. Additional observation showed the extension cord painted with intumescent paint and covered with fire caulk at the point of wall penetration.

During an interview on 2/09/2017 staff (I) said extension cords were used during attic painting and insulation work and were never removed after the work was completed.

Refer to NFPA 70, National Electrical Code, 2011 edition, Article 400.8 for additional information.

Based on observation,record review and facility staff interview, facility staff failed to store oxygen tanks per NFPA 99, Health Care Facilities Code, 2012 edition. The facility census was 25.

Observation on 1/26/2017, of the storage room on the break room hall, showed the following:

-19 oxygen tanks size E stored in the designated storage room.

-The 20 feet by 20 feet storage room contained multiple isles of racks with linens, decorations and miscellaneous combustible storage.

-The storage room floor covered with wall to wall carpet.

-The door to the room did not have a self closing device.

During an interview on 2/09/2017 staff (I) said hospital staff did not follow the posted policy of limiting oxygen storage to 12 tanks. Additionally, he/she said the building did not have a designated oxygen storage room.

Record review of NFPA 99, Health Care Facilities Code, 2012 edition, Table A.9.3.7.5.1 showed tank size "E" measures 4.5 inches diameter by 26 inches tall and contains 23 cubic feet of oxygen per tank.
Observation showed 19 oxygen tanks size "E" stored in the room. The total quantity of oxygen in the tanks was 437 cubic feet.

5.1.3.3.2* Design and Construction. Locations for central supply
systems and the storage of positive-pressure gases shall
meet the following requirements:
(1) They shall be constructed with access to move cylinders,
equipment, and so forth, in and out of the location on
hand trucks complying with 11.4.3.1.1.
(2) They shall be secured with lockable doors or gates or
otherwise secured.
(3) If outdoors, they shall be provided with an enclosure
(wall or fencing) constructed of noncombustible materials
with a minimum of two entry/exits.
(4) If indoors, they shall be constructed and use interior finishes
of noncombustible or limited-combustible materials
such that all walls, floors, ceilings, and doors are of a
minimum 1-hour fire resistance rating.
(5)*They shall be compliant with NFPA 70, National Electrical
Code, for ordinary locations.
(6) They shall be heated by indirect means (e.g., steam, hot
water) if heat is required.
(7) They shall be provided with racks, chains, or other fastenings
to secure all cylinders from falling, whether connected,
unconnected, full, or empty.
(8)*They shall be supplied with electrical power compliant
with the requirements for essential electrical systems as
described in Chapter 6.
(9) They shall have racks, shelves, and supports, where provided,
constructed of noncombustible materials or
limited-combustible materials.
(10) They shall protect electrical devices from physical damage.
5.1.3.3.4 Storage.
5.1.3.3.4.1 Full or empty medical gas cylinders, when not connected,
shall be stored in locations complying with 5.1.3.3.2
through 5.1.3.3.3 and shall be permitted to be in the same rooms
or enclosures as their respective central supply systems.
5.1.3.3.4.2 Cylinders, whether full or empty, shall not be stored
in enclosures containing motor-driven machinery, with the exception
of cylinders intended for instrument air reserve headers
complying with 5.1.3.9.5, which shall be permitted to be placed
in the same location containing an instrument air compressor
when it is the only motor-driven machinery located within the
room. Only cylinders intended for instrument air reserve headers
complying with 5.1.3.9.5 shall be permitted to be stored in
enclosures containing instrument air compressors.