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Based on observation, the facility failed to ensure that exit signage was clear and identifiable. Failure to properly identify the clear path of egress would hinder evacuation during and emergency. The facility is licensed for 25 Hospital beds and had a census of 8 on the date of the survey.

Findings include:

1) During the facility tour conducted on September 4, 2015 from 11:45 AM to 3:45 PM, observation of the exit discharge area at the west side of the building entering the ramp to the clinic, the installed exit sign above the ramp provided no clear direction of travel.

2) During the facility tour conducted on September 4, 2015 from 11:45 AM to 3:45 PM, observation of two (2) exit signs installed in the emergency suite revealed the directional arrows pointed to dead end walls, not to an exit.

Actual NFPA standard:

7.10.1.2* Exits.
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

7.10.1.4* Exit Access.
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. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.

Based on observation and interview, the facility failed to ensure that sprinkler heads were not of mixed type and response in a compartment. Dissimilar heads in a covered area could affect the system capability to control fires in incipient stages. The facility is licensed for 25 Hospital beds and had a census of 8 on the date of the survey.

Findings include:

During the facility tour conducted on September 4, 2015 from 11:45 AM to 3:45 PM, observation of Storage Room #4 and the Employee Breakroom adjacent to Elevator "G" revealed: standard response high-temperature/high hazard sprinkler heads mixed with quick response, ordinary hazard sprinkler heads; one (1) at each location. Further inspection demonstrated neither location was exposed to a high temperature hazard.

Interview of the Maintenance Director found he had not been aware these mixed heads were present.

Actual NFPA standard:

NFPA 13
5-3.1.4 Temperature Ratings.
5-3.1.4.2
The following practices shall be observed to provide sprinklers of other than ordinary temperature classification unless other temperatures are determined or unless high-temperature sprinklers are used throughout [see Tables 5-3.1.4.2(a) and (b) and Figure 5-3.1.4.2].
(1) Sprinklers in the high-temperature zone shall be of the high-temperature classification, and sprinklers in the intermediate-temperature zone shall be of the intermediate-temperature classification.
(2) Sprinklers located within 12 in. (305 mm) to one side or 30 in. (762 mm) above an uncovered steam main, heating coil, or radiator shall be of the intermediate-temperature classification.
(3) Sprinklers within 7 ft (2.1 m) of a low-pressure blowoff valve that discharges free in a large room shall be of the high-temperature classification.
(4) Sprinklers under glass or plastic skylights exposed to the direct rays of the sun shall be of the intermediate-temperature classification.
(5) Sprinklers in an unventilated, concealed space, under an uninsulated roof, or in an unventilated attic shall be of the intermediate-temperature classification.
(6) Sprinklers in unventilated show windows having high-powered electric lights near the ceiling shall be of the intermediate-temperature classification.
(7) Sprinklers protecting commercial-type cooking equipment and ventilation systems shall be of the high- or extra-high-temperature classification as determined by use of a temperature-measuring device. (See 4-9.6.)

5-4.5.3
Where residential sprinklers are installed in a compartment as defined in 1-4.2, all sprinklers within the compartment shall be of the fast-response type that meets the criteria of 1-4.5.1(a)1.

Based on observation and operational testing, the facility failed to ensure that exit doors were free of impediments to their instant use. Failure to provide instant use for exits would hinder evacuation during an emergency. The facility is licensed for 25 Hospital beds and had a census of 8 on the day of the survey.

Findings include:

During the facility tour conducted on September 4, 2015 from 11:45 AM to 3:45 PM, observation and operational testing of the exit door of the southeast exit from the OB suite found it was equipped with a electronic controlled keypad without a delayed egress component.

Actual NFPA standard:

7.2.1.5.6*
Devices shall not be installed in connection with any door on which panic hardware or fire exit hardware is required where such device prevents or is intended to prevent the free use of the door for purposes of egress.
Exception: This requirement shall not apply where otherwise provided in 7.2.1.6.

7.2.1.6 Special Locking Arrangements.
7.2.1.6.1 Delayed-Egress Locks.
Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met.
(a) The doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with Section 9.7 or upon the actuation of any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6.
(b) The doors shall unlock upon loss of power controlling the lock or locking mechanism.
(c) An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only.
Exception: Where approved by the authority having jurisdiction, a delay not exceeding 30 seconds shall be permitted.
(d) * On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS

Based on observation, the facility failed to ensure that exit signage was clear and identifiable. Failure to properly identify the clear path of egress would hinder evacuation during and emergency. The facility is licensed for 25 Hospital beds and had a census of 8 on the date of the survey.

Findings include:

1) During the facility tour conducted on September 4, 2015 from 11:45 AM to 3:45 PM, observation of the exit discharge area at the west side of the building entering the ramp to the clinic, the installed exit sign above the ramp provided no clear direction of travel.

2) During the facility tour conducted on September 4, 2015 from 11:45 AM to 3:45 PM, observation of two (2) exit signs installed in the emergency suite revealed the directional arrows pointed to dead end walls, not to an exit.

Actual NFPA standard:

7.10.1.2* Exits.
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

7.10.1.4* Exit Access.
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. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.

Based on observation and interview, the facility failed to ensure that sprinkler heads were not of mixed type and response in a compartment. Dissimilar heads in a covered area could affect the system capability to control fires in incipient stages. The facility is licensed for 25 Hospital beds and had a census of 8 on the date of the survey.

Findings include:

During the facility tour conducted on September 4, 2015 from 11:45 AM to 3:45 PM, observation of Storage Room #4 and the Employee Breakroom adjacent to Elevator "G" revealed: standard response high-temperature/high hazard sprinkler heads mixed with quick response, ordinary hazard sprinkler heads; one (1) at each location. Further inspection demonstrated neither location was exposed to a high temperature hazard.

Interview of the Maintenance Director found he had not been aware these mixed heads were present.

Actual NFPA standard:

NFPA 13
5-3.1.4 Temperature Ratings.
5-3.1.4.2
The following practices shall be observed to provide sprinklers of other than ordinary temperature classification unless other temperatures are determined or unless high-temperature sprinklers are used throughout [see Tables 5-3.1.4.2(a) and (b) and Figure 5-3.1.4.2].
(1) Sprinklers in the high-temperature zone shall be of the high-temperature classification, and sprinklers in the intermediate-temperature zone shall be of the intermediate-temperature classification.
(2) Sprinklers located within 12 in. (305 mm) to one side or 30 in. (762 mm) above an uncovered steam main, heating coil, or radiator shall be of the intermediate-temperature classification.
(3) Sprinklers within 7 ft (2.1 m) of a low-pressure blowoff valve that discharges free in a large room shall be of the high-temperature classification.
(4) Sprinklers under glass or plastic skylights exposed to the direct rays of the sun shall be of the intermediate-temperature classification.
(5) Sprinklers in an unventilated, concealed space, under an uninsulated roof, or in an unventilated attic shall be of the intermediate-temperature classification.
(6) Sprinklers in unventilated show windows having high-powered electric lights near the ceiling shall be of the intermediate-temperature classification.
(7) Sprinklers protecting commercial-type cooking equipment and ventilation systems shall be of the high- or extra-high-temperature classification as determined by use of a temperature-measuring device. (See 4-9.6.)

5-4.5.3
Where residential sprinklers are installed in a compartment as defined in 1-4.2, all sprinklers within the compartment shall be of the fast-response type that meets the criteria of 1-4.5.1(a)1.

Based on observation and operational testing, the facility failed to ensure that exit doors were free of impediments to their instant use. Failure to provide instant use for exits would hinder evacuation during an emergency. The facility is licensed for 25 Hospital beds and had a census of 8 on the day of the survey.

Findings include:

During the facility tour conducted on September 4, 2015 from 11:45 AM to 3:45 PM, observation and operational testing of the exit door of the southeast exit from the OB suite found it was equipped with a electronic controlled keypad without a delayed egress component.

Actual NFPA standard:

7.2.1.5.6*
Devices shall not be installed in connection with any door on which panic hardware or fire exit hardware is required where such device prevents or is intended to prevent the free use of the door for purposes of egress.
Exception: This requirement shall not apply where otherwise provided in 7.2.1.6.

7.2.1.6 Special Locking Arrangements.
7.2.1.6.1 Delayed-Egress Locks.
Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met.
(a) The doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with Section 9.7 or upon the actuation of any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6.
(b) The doors shall unlock upon loss of power controlling the lock or locking mechanism.
(c) An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only.
Exception: Where approved by the authority having jurisdiction, a delay not exceeding 30 seconds shall be permitted.
(d) * On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS