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One-story buildings of Type II (000) construction are required to be protected by an automatic sprinkler system. Without a sprinkler system, Type II (111) construction is required. 19.1.6.2, 19.3.5.1

The facility failed to provide a construction type that met the requirements of the Life Safety Code.

Observation determined the steel I-beams and columns were not protected as a one-hour fire rated assembly.
Failure to meet the requirements of building construction type increases the risk of death or injury due to fire.

This deficiency affected the entire facility.

A functional test must be conducted on every required emergency lighting system at 30-day intervals for a minimum of 30 seconds. An annual test must be conducted for 1 1/2-hour duration. Written records of testing must be kept by the owner for inspection by the authority having jurisdiction. 19.2.9.1, 7.9.3

Review of records indicated the facility failed to conduct annual 1 1/2-hour tests on emergency battery pack lights in the past year.

Failure to provide emergency lighting as required increases the risk of death or injury due to fire.

The deficiency affected all emergency battery back-up lights throughout the building.

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.

On 10/31/2016, fire drill records indicated the last six (6) fire drills for the Night shift occurred at 7:00pm, 7:30pm, 7:30pm, 7:30pm, 9:00pm and 7:00 pm. Fire drills are required to be conducted under varied conditions. The condition of the time of the day was not varied. Five (5) fire drills in the past year all occurred at times within 30 minutes of each other in a 12 hour shift.

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

The deficiency affected five (5) of twelve (12) drills in the past year.

The facility failed to install the fire alarm system in accordance with NFPA 72, National Fire Alarm Code.

The fire alarm panel was located in the Boiler Room.

Observation determined an annunciation panel was not provided at a constantly occupied area (Nurses Station). The annunciation panel must monitor the fire alarm panel's primary functions:

1) Audible and visible signal that would indicate system trouble.

2) Visible signals that indicated which fire alarm zone is into alarm.

3) Audible and visible monitor the of fire alarm system supervisory signal.

Failure to install the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) fire alarm system in the facility, which serves the entire building.

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with NFPA 72, National Fire Alarm Code.

1) Fire alarm system batteries shall be subjected to a load voltage test semiannually. NFPA 72 7-3.2

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 most current fire alarm system batteries load voltage test was conducted on 10/26/2016 and the previous test was conducted on 11/03/2015, exceeding the required semiannual testing requirement.

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

This deficiency affected one (1) of two (2) required load voltage tests of the fire alarm batteries in the past year.

2) System defects and malfunctions shall be corrected. NFPA 72 7-1.1.2

Review of fire alarm system test records indicated seven (7) heat detectors failed when tested on 10/26/2016 and had not been replaced.

Failure to maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

The deficiency affected seven (7) of sixteen (16) heat detectors in the facility.

The sealed lead acid batteries and heat detectors are components of the complete fire alarm system, which serves the entire 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, NFPA 72 2-3.5.1

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

Observation determined the smoke detector located by the west cross-corridor smoke barrier doors in the north smoke compartment was installed within three feet of an air supply diffuser.

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

This deficiency affected one (1) of numerous smoke detectors in the facility.

1) 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. NFPA 110 3-5.5.6

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 outside of the generator room.

2) 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 outside of the Generator Room at a work site readily observable by personnel.

Failure to ensure the emergency generator is in compliance with NFPA 99 and 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.

One-story buildings of Type II (000) construction are required to be protected by an automatic sprinkler system. Without a sprinkler system, Type II (111) construction is required. 19.1.6.2, 19.3.5.1

The facility failed to provide a construction type that met the requirements of the Life Safety Code.

Observation determined the steel I-beams and columns were not protected as a one-hour fire rated assembly.
Failure to meet the requirements of building construction type increases the risk of death or injury due to fire.

This deficiency affected the entire facility.

A functional test must be conducted on every required emergency lighting system at 30-day intervals for a minimum of 30 seconds. An annual test must be conducted for 1 1/2-hour duration. Written records of testing must be kept by the owner for inspection by the authority having jurisdiction. 19.2.9.1, 7.9.3

Review of records indicated the facility failed to conduct annual 1 1/2-hour tests on emergency battery pack lights in the past year.

Failure to provide emergency lighting as required increases the risk of death or injury due to fire.

The deficiency affected all emergency battery back-up lights throughout the building.

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.

On 10/31/2016, fire drill records indicated the last six (6) fire drills for the Night shift occurred at 7:00pm, 7:30pm, 7:30pm, 7:30pm, 9:00pm and 7:00 pm. Fire drills are required to be conducted under varied conditions. The condition of the time of the day was not varied. Five (5) fire drills in the past year all occurred at times within 30 minutes of each other in a 12 hour shift.

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

The deficiency affected five (5) of twelve (12) drills in the past year.

The facility failed to install the fire alarm system in accordance with NFPA 72, National Fire Alarm Code.

The fire alarm panel was located in the Boiler Room.

Observation determined an annunciation panel was not provided at a constantly occupied area (Nurses Station). The annunciation panel must monitor the fire alarm panel's primary functions:

1) Audible and visible signal that would indicate system trouble.

2) Visible signals that indicated which fire alarm zone is into alarm.

3) Audible and visible monitor the of fire alarm system supervisory signal.

Failure to install the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) fire alarm system in the facility, which serves the entire building.

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with NFPA 72, National Fire Alarm Code.

1) Fire alarm system batteries shall be subjected to a load voltage test semiannually. NFPA 72 7-3.2

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 most current fire alarm system batteries load voltage test was conducted on 10/26/2016 and the previous test was conducted on 11/03/2015, exceeding the required semiannual testing requirement.

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

This deficiency affected one (1) of two (2) required load voltage tests of the fire alarm batteries in the past year.

2) System defects and malfunctions shall be corrected. NFPA 72 7-1.1.2

Review of fire alarm system test records indicated seven (7) heat detectors failed when tested on 10/26/2016 and had not been replaced.

Failure to maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

The deficiency affected seven (7) of sixteen (16) heat detectors in the facility.

The sealed lead acid batteries and heat detectors are components of the complete fire alarm system, which serves the entire 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, NFPA 72 2-3.5.1

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

Observation determined the smoke detector located by the west cross-corridor smoke barrier doors in the north smoke compartment was installed within three feet of an air supply diffuser.

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

This deficiency affected one (1) of numerous smoke detectors in the facility.

1) 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. NFPA 110 3-5.5.6

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 outside of the generator room.

2) 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 outside of the Generator Room at a work site readily observable by personnel.

Failure to ensure the emergency generator is in compliance with NFPA 99 and 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.