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Based on facility observation, review of facility schematics and staff interview and verification, the facility failed to ensure if the building had a common wall with a nonconforming building, the common wall is a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition. The facility census was 8 patients at the time of the survey.

Findings included:

On 09/7/13, at 9:00 A.M., Review of the facility schematic revealed a two hour fire rated barrier was located between the exiting building and the new building. The new building was determined to be construction type II (222) with fire alarm, smoke detection, and automatic sprinkler protection systems. The existing building was constructed between 1915 and 1984 with fire alarm and smoke detection systems only. The construction type of the existing building was determined to be V(000). The barrier wall observed was located in a conference room in the existing building.

Observation above the ceiling tiles revealed the presence of three, four inch white pipe sleeves. The three pipes extended through the barrier wall. Observed inside the pipes was a yellow wool which did not allow for any visual sign of light. However at one of the three pipes a draft of cool air could be felt. Staff G verified the presence of the cool air. Staff G could not verify the wool stuffed into the pipe sleeves provided enough protection to maintain a two hour fire rated barrier between the existing building and the new building.

Based on facility observation and staff interview and verification, the facility failed to ensure that building construction type and height met the requirements for a three story building without a complete automatic sprinkler system. The facility had a census of eight patients at the time of the survey.

Findings included;

On 09/17/13 between 8:35 A.M. and 11:10 A.M. tour of the first floor was conducted with Staff G. Observation above the ceiling tiles in the following rooms revealed the presence of unprotected steel beams and supportive structures;

1. Located on the first floor, conference room, an unprotected steel deck was observed.

2. Located in the St. Francis Corridor, a steel support structure was observed with no fire protective spray.

3. Observed above the ceiling tiles in room 1.111, a steel I-beam support was observed with no fire protective covering.

4. Observed above the ceiling tiles in the corridor near room 1.112, a steel support beam was observed with no fireproof spray.

5. Located in storage area 1.120, observation above the ceiling tiles revealed a Steel I-beam with no fireproof covering.

Observation of the third floor revealed leased space to another hospital. The facility was a secured psychiatric unit for adult and geriatric patients. At the time of survey the facility had 16 patient beds with a census of 16 patients.

Staff G, present on tour verified the observations. Interview of Staff G verified the facility lacked automatic sprinkler protection and was three stores in height. It was further verified the steel support structures of the facility lacked any type for fire protective application. Staff G and H revealed that an outside contractor had conducted a fire safety evaluation system (FSES) in August 2013. The facility failed to meet the protection requirements and was in discussion regarding the installation of an automatic sprinkler system.

Based on facility observation and staff interview and verification, the facility failed to ensure that corridors were separated from use areas by walls constructed with at least ? hour fire resistance rating. In non-sprinklered buildings, walls properly extend above the ceiling. The facility had a census of eight patients at the time of the survey.

Findings included

Observation of the facility was conducted with Staff G and H on 09/16/13 between 10:55 A.M. and 3:40 P.M. and 09/17/13 between 8:35 A.M. and 4:45 P.M. The following observations of corridor walls were noted in the facility;

Third floor

1. Located above the ceiling tiles, near room 3.110, one to two inch penetrations in the old lathe ceiling surrounding hangers for the suspended ceiling.

2. Located above the ceiling tiles, near office 3.113 and the north stairwell, a one foot by two foot open access which allowed for visibility of the roof decking above.

3. Located above the ceiling tiles, in the same corridor and near room 3.100, one to two inch penetrations in the old lathe ceiling surrounding at least eight hangers for the suspended ceiling.

Second floor

1. Observation above the ceiling tiles, at room 2.176, used for storage, revealed the corridor wall did not extend to the decking above. Staff G indicated the second floor housed administrative offices and storage so was considered business occupancy. Staff G verified that penetrations above the ceiling were present in corridor walls

2. Observation of a former nurses station, across from room 2.141, revealed the area was enclosed by glass panels. The glass area was 15 feet in length and four feet in height. At each side of the nursing station was a glass panel that measured 36 inches wide by 38 inches in height. Staff G stated the area was currently used as a central scheduling area for patients.

3, A second scheduling area near room 2.107, was noted to be enclosed by three glass panels. The panels were 37 inches in height and 33 inches wide.

Written information provided by Staff G on 09/20/13 at 1:25 P.M. revealed the observed glass at the central scheduling areas in the corridor had no fire resistance rating.

First floor

1. Observation above the ceiling tiles in the St. Francis corridor, near the large conference room, the area at the junction of the corridor wall and the floor decking above was not sealed. This was noted on both sides of the corridor.

2. Observation above the ceiling tiles at three storage closets, 1.111, 1.113 and 1.115 revealed the corridor wall did not extended to the decking above and the closets had no ceilings.

3. Observation above the ceiling tiles at an IT closet, 1.117, revealed an unsealed area at the decking above.

4. Observation above the ceiling tiles at a set of three hour fire rated doors, in an exit corridor, revealed a large open area that was that did not extend to the decking above.

5. Observation above the ceiling tiles in the Specialty Clinic corridor, near the receptionist area, revealed multiple penetrations in the lathe ceiling above, surrounding the hangers for the suspended ceiling.

6. Located in the purchasing hall, at room 1.142, observation above the ceiling tiles revealed an open area approximately 12 feet in length by 1 foot in width.

7. Observation above ceiling tiles in the dock corridor, revealed a four inch by 12 inch penetration in the corridor wall where flexible conduit was inserted. A second penetration, one inch by one inch, was noted where flex cable was inserted.

All observations were verified by Staff G present on the tour.

Based on facility observation and staff interview and verification, the facility failed to ensure that door openings in smoke barriers have at least a 20-minute fire protection rating and that doors were self-closing and rabbets, bevels or astragals were required at the meeting edges. The facility had a census of eight patients at the time of the survey.

Findings included:

On 09/17/13 between 1:30 P.M. and 4:45 P.M., tour of the first floor was conducted with Staff G and H. Observation of the smoke barrier doors located in the corridor near the emergency room department, revealed that when in the closed position, the edges of the doors were greater than 1/8 inch apart.

The observation was verified by Staff G. Staff G further revealed that astragals had been ordered but had not yet been received at the facility.

Based on review of facility schematics, facility observation and staff interview and verification, the facility failed to ensure that one hour fire rated construction (with ? hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. Doors were to be self-closing The facility had a census of eight patients at the time of the survey.

Findings included

Observation of the facility was conducted with Staff G and H on 09/16/13 between 10:55 A.M. and 3:40 P.M. and 09/17/13 between 8:35 A.M. and 4:45 P.M. The following observations of storage areas and mechanical areas were noted in the facility;

Third Floor

1. Observation of room 3.100, identified by Staff G to be a storage room for the leased tenant of the third floor, revealed the room was located outside the leased space and was in the facility. The contents of the room included patient care equipment and cardboard boxes. Observation of the door to the room revealed there was no fire resistance rating.

2. Observation of a storage room with a one hour fire rated all, used to store combustible paper files, revealed at least three penetrations in the lathe ceiling surrounding hangers for the suspended ceiling.

3. Observation of a one hour fire rated storage room, identified as the medical records file room, revealed a wood door that lead to a human resources office. Observation of the wood door revealed there was no fire resistance rating on the door. The room contained at least 12 cardboard file boxes of paper records.

Second floor

1. Observation of storage room 2.127, revealed no one hour fire resistant construction of the walls and no fire resistance rating for the door to the room.

2. Observation of storage room 2.125, revealed storage of children's books. The door to the room had no fire resistance rating.

3. Observation of storage room 2.176, revealed storage of Christmas decorations, combustible boxes, empty plastic bottles and an electrical panel. Two boxes and Christmas decorations were stored on wooden shelves closer than 36 inches from the front of the electrical panel box. The door to the room was noted to have a 20 minute fire resistance rating and no self-closing device.

4. Observation of storage room 2.166, revealed storage of medical records. The door to the room had no fire resistance rating and no self-closing device. Observation above the ceiling tiles revealed the room did not have one hour fire resistant construction.

First floor

1. Observation of storage room 1.143, used by the facility pharmacy, revealed at least nine penetrations of various sizes in the area above the ceiling tiles. The largest penetration was approximately eight inches by
10 inches in diameter. The penetrations surrounded ducts and pipes that extended through the walls. A long narrow penetrations, approximately eight feet long and 2 inches wide was noted in the lathe ceiling above the ceiling tiles. The wood door to the room had louvers for ventilation.

2. Observation of storage room 1.120 was used to store surgical supplies. The room had soiled and stained carpet. Observation above the ceiling tiles revealed a black pipe, identified by Staff G to be a pipe from a toilet in a former bathroom on the floor above. The black pipe extended through the floor decking above the ceiling tiles. The door to the storage room had a 20 minute fire resistance rating.

An additional storage area attached to the same room was observed to have an open area 16 feet in length and one foot in width above the ceiling tiles. The open area was located in a wall that separated the storage area from a physician's office.

3. Observation above the ceiling tiles from a mechanical room with electrical equipment, revealed an open area approximately 22 feet long and 18 inches wide in the wall between the electrical room and a biomedical office, 1.124.

4. Observation of a mechanical room, 1.138, revealed penetrations surrounding multiple pipes and hot water lines.

5. Observation of two doors, one located on the "musak" room and the other located on the elevator hydraulic room revealed no fire resistance rating.

6. Observation of a mechanical room, formerly known as the boiler room, was noted to have a
door with nine panels of non-fire rated glass. The door had no fire resistance rating.

Observations were verified by Staff G and H present on the tour.

Based on review of facility schematics, facility observation and staff interview and verification, the facility failed to ensure that one hour fire rated construction with ? hour fire-rated doors in accordance with 8.4 protected hazardous areas. Doors were to be self-closing or automatic closing The facility had a census of eight patients at the time of the survey.

Findings included

Observation of the facility was conducted with Staff G and H on 09/17/13 between 1:30 P.M. and 4:45 P.M. The following storage areas were lacking appropriate fire rated construction

1. Observation of room G.027 revealed the door to the soiled utility room had no fire resistance rating and no self-closing or automatic closing device in place.

2. Observation above the ceiling tiles of storage area, G.068, revealed three penetrations located at a large duct.

3. Observation of storage room G.057 revealed two doors to the room. Both doors had no fire resistance rating and lacked self-closing or automatic closing devices. Observation above the ceiling tiles revealed an open area two feet wide by five feet long open to the deck above. Review of the facility schematic verified the room was to have a one hour fire rated construction.

Staff G and H present on the tour verified the observations.

Based on facility observation and staff interview and verification, the facility failed to ensure that exit access to the public way was maintained. One exit was affected. The facility had a census of 8 patients at the time of the survey.

Findings included;

On 09/17/13 at 10:25 A.M. observation with Staff G and H was conducted of an exit located in the waiting area of the Specialty Clinic. The exit discharge was noted to be through large double doors. Staff H verified the doors were once the main entrance to the facility.

Observation of the exit discharge revealed a concrete pad approximately ten feet wide. A sloped grassy area was observed off the concrete pad. A metal fence like barrier, approximately four feet in height, surrounded the grassy area and was designed to prevent anyone in the grassy area from falling from the sloped area. Travel to the public way, a parking lot, required travel in the uneven grassy area for approximately 60 feet. There was no gate in the metal fence once the paved parking lot was reached.

Staff G and H verified that upon exit from the building to the enclosed, uneven, grassy area, the paved parking lot could not be reached due to the fence.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency lighting of at least 1? hour duration was provided and that testing was conducted for 30 seconds per month. The facility had a census of 8 patients at the time of the survey.

Findings included;

Observation of the facility was conducted with Staff G and H on 09/17/13 between 8:35 A.M. and 4:45 P.M. The facility was noted to have emergency battery operated lighting at various areas of the facility. Staff G verified that testing of the battery operated emergency lighting was conducted.

On 09/19/13 at 1:05 P.M., review of facility testing documentation with Staff Z revealed that emergency lighting was noted as tested. There was no indication the monthly testing was for a period of 30 seconds and there was no indication of a 90 minute test annually. Staff Z verified that documentation did not reflect a 90 minute test per year or a test for 30 seconds per month.

Based on facility observation and staff interview and verification, the facility failed to ensure that soiled linen receptacles did not exceed 32 gal (121 L) in capacity and that a capacity of 32 gal (121 L) was not exceeded within any 64 sq ft (5.9-sq m) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) were to be located in a room protected as a hazardous area when not attended. The facility had a census of eight patients at the time of the survey.

Findings included

Observation of the facility was conducted with Staff G and H on 09/16/13 between 10:55 A.M. and 3:40 P.M. and 09/17/13 between 8:35 A.M. and 4:45 P.M. Observation of an area on the first floor identified as the old emergency department entrance was noted to be the location of four large wheeled containers. The four large wheeled carts were full of bags of soiled linens and were stored at the entrance to the former emergency department.

Interview of Staff G revealed the area was the typical location for storage of the soiled linen containers until the contracted company picks up the soiled linens. Staff G further verified the location of the stored containers was not considered a hazardous storage area. The area was to be renovated in the future to be an acceptable storage area for the containers. Staff G and H verified the contracted company picks up the soiled linens about every two days.

NFPA 72
Chapter 7

7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that detector sensitivity was tested every alternate year thereafter the one year installation After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

Findings included:

On 09/18/13 at 11:15 A.M. , review of facility documentation was conducted with Staff G. Review of completed testing information for the fire alarm and smoke detection systems revealed there was no documented evidence of smoke sensitivity testing since October 2009. Staff G verified the information.

On 09/19/13, at 2:40 P.M., Staff G provided information that indicated the smoke detector sensitivity had been tested that day. Staff G verified an oversight had occurred and the testing had not previously been completed.

Based on facility observation, review of facility schematics and staff interview and verification, the facility failed to ensure if the building had a common wall with a nonconforming building, the common wall is a fire barrier having at least a two-hour fire resistance rating constructed of materials as required for the addition. The facility census was 8 patients at the time of the survey.

Findings included:

On 09/7/13, at 9:00 A.M., Review of the facility schematic revealed a two hour fire rated barrier was located between the exiting building and the new building. The new building was determined to be construction type II (222) with fire alarm, smoke detection, and automatic sprinkler protection systems. The existing building was constructed between 1915 and 1984 with fire alarm and smoke detection systems only. The construction type of the existing building was determined to be V(000). The barrier wall observed was located in a conference room in the existing building.

Observation above the ceiling tiles revealed the presence of three, four inch white pipe sleeves. The three pipes extended through the barrier wall. Observed inside the pipes was a yellow wool which did not allow for any visual sign of light. However at one of the three pipes a draft of cool air could be felt. Staff G verified the presence of the cool air. Staff G could not verify the wool stuffed into the pipe sleeves provided enough protection to maintain a two hour fire rated barrier between the existing building and the new building.

Based on facility observation and staff interview and verification, the facility failed to ensure that building construction type and height met the requirements for a three story building without a complete automatic sprinkler system. The facility had a census of eight patients at the time of the survey.

Findings included;

On 09/17/13 between 8:35 A.M. and 11:10 A.M. tour of the first floor was conducted with Staff G. Observation above the ceiling tiles in the following rooms revealed the presence of unprotected steel beams and supportive structures;

1. Located on the first floor, conference room, an unprotected steel deck was observed.

2. Located in the St. Francis Corridor, a steel support structure was observed with no fire protective spray.

3. Observed above the ceiling tiles in room 1.111, a steel I-beam support was observed with no fire protective covering.

4. Observed above the ceiling tiles in the corridor near room 1.112, a steel support beam was observed with no fireproof spray.

5. Located in storage area 1.120, observation above the ceiling tiles revealed a Steel I-beam with no fireproof covering.

Observation of the third floor revealed leased space to another hospital. The facility was a secured psychiatric unit for adult and geriatric patients. At the time of survey the facility had 16 patient beds with a census of 16 patients.

Staff G, present on tour verified the observations. Interview of Staff G verified the facility lacked automatic sprinkler protection and was three stores in height. It was further verified the steel support structures of the facility lacked any type for fire protective application. Staff G and H revealed that an outside contractor had conducted a fire safety evaluation system (FSES) in August 2013. The facility failed to meet the protection requirements and was in discussion regarding the installation of an automatic sprinkler system.

Based on facility observation and staff interview and verification, the facility failed to ensure that corridors were separated from use areas by walls constructed with at least ? hour fire resistance rating. In non-sprinklered buildings, walls properly extend above the ceiling. The facility had a census of eight patients at the time of the survey.

Findings included

Observation of the facility was conducted with Staff G and H on 09/16/13 between 10:55 A.M. and 3:40 P.M. and 09/17/13 between 8:35 A.M. and 4:45 P.M. The following observations of corridor walls were noted in the facility;

Third floor

1. Located above the ceiling tiles, near room 3.110, one to two inch penetrations in the old lathe ceiling surrounding hangers for the suspended ceiling.

2. Located above the ceiling tiles, near office 3.113 and the north stairwell, a one foot by two foot open access which allowed for visibility of the roof decking above.

3. Located above the ceiling tiles, in the same corridor and near room 3.100, one to two inch penetrations in the old lathe ceiling surrounding at least eight hangers for the suspended ceiling.

Second floor

1. Observation above the ceiling tiles, at room 2.176, used for storage, revealed the corridor wall did not extend to the decking above. Staff G indicated the second floor housed administrative offices and storage so was considered business occupancy. Staff G verified that penetrations above the ceiling were present in corridor walls

2. Observation of a former nurses station, across from room 2.141, revealed the area was enclosed by glass panels. The glass area was 15 feet in length and four feet in height. At each side of the nursing station was a glass panel that measured 36 inches wide by 38 inches in height. Staff G stated the area was currently used as a central scheduling area for patients.

3, A second scheduling area near room 2.107, was noted to be enclosed by three glass panels. The panels were 37 inches in height and 33 inches wide.

Written information provided by Staff G on 09/20/13 at 1:25 P.M. revealed the observed glass at the central scheduling areas in the corridor had no fire resistance rating.

First floor

1. Observation above the ceiling tiles in the St. Francis corridor, near the large conference room, the area at the junction of the corridor wall and the floor decking above was not sealed. This was noted on both sides of the corridor.

2. Observation above the ceiling tiles at three storage closets, 1.111, 1.113 and 1.115 revealed the corridor wall did not extended to the decking above and the closets had no ceilings.

3. Observation above the ceiling tiles at an IT closet, 1.117, revealed an unsealed area at the decking above.

4. Observation above the ceiling tiles at a set of three hour fire rated doors, in an exit corridor, revealed a large open area that was that did not extend to the decking above.

5. Observation above the ceiling tiles in the Specialty Clinic corridor, near the receptionist area, revealed multiple penetrations in the lathe ceiling above, surrounding the hangers for the suspended ceiling.

6. Located in the purchasing hall, at room 1.142, observation above the ceiling tiles revealed an open area approximately 12 feet in length by 1 foot in width.

7. Observation above ceiling tiles in the dock corridor, revealed a four inch by 12 inch penetration in the corridor wall where flexible conduit was inserted. A second penetration, one inch by one inch, was noted where flex cable was inserted.

All observations were verified by Staff G present on the tour.

Based on facility observation and staff interview and verification, the facility failed to ensure that door openings in smoke barriers have at least a 20-minute fire protection rating and that doors were self-closing and rabbets, bevels or astragals were required at the meeting edges. The facility had a census of eight patients at the time of the survey.

Findings included:

On 09/17/13 between 1:30 P.M. and 4:45 P.M., tour of the first floor was conducted with Staff G and H. Observation of the smoke barrier doors located in the corridor near the emergency room department, revealed that when in the closed position, the edges of the doors were greater than 1/8 inch apart.

The observation was verified by Staff G. Staff G further revealed that astragals had been ordered but had not yet been received at the facility.

Based on review of facility schematics, facility observation and staff interview and verification, the facility failed to ensure that one hour fire rated construction (with ? hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. Doors were to be self-closing The facility had a census of eight patients at the time of the survey.

Findings included

Observation of the facility was conducted with Staff G and H on 09/16/13 between 10:55 A.M. and 3:40 P.M. and 09/17/13 between 8:35 A.M. and 4:45 P.M. The following observations of storage areas and mechanical areas were noted in the facility;

Third Floor

1. Observation of room 3.100, identified by Staff G to be a storage room for the leased tenant of the third floor, revealed the room was located outside the leased space and was in the facility. The contents of the room included patient care equipment and cardboard boxes. Observation of the door to the room revealed there was no fire resistance rating.

2. Observation of a storage room with a one hour fire rated all, used to store combustible paper files, revealed at least three penetrations in the lathe ceiling surrounding hangers for the suspended ceiling.

3. Observation of a one hour fire rated storage room, identified as the medical records file room, revealed a wood door that lead to a human resources office. Observation of the wood door revealed there was no fire resistance rating on the door. The room contained at least 12 cardboard file boxes of paper records.

Second floor

1. Observation of storage room 2.127, revealed no one hour fire resistant construction of the walls and no fire resistance rating for the door to the room.

2. Observation of storage room 2.125, revealed storage of children's books. The door to the room had no fire resistance rating.

3. Observation of storage room 2.176, revealed storage of Christmas decorations, combustible boxes, empty plastic bottles and an electrical panel. Two boxes and Christmas decorations were stored on wooden shelves closer than 36 inches from the front of the electrical panel box. The door to the room was noted to have a 20 minute fire resistance rating and no self-closing device.

4. Observation of storage room 2.166, revealed storage of medical records. The door to the room had no fire resistance rating and no self-closing device. Observation above the ceiling tiles revealed the room did not have one hour fire resistant construction.

First floor

1. Observation of storage room 1.143, used by the facility pharmacy, revealed at least nine penetrations of various sizes in the area above the ceiling tiles. The largest penetration was approximately eight inches by
10 inches in diameter. The penetrations surrounded ducts and pipes that extended through the walls. A long narrow penetrations, approximately eight feet long and 2 inches wide was noted in the lathe ceiling above the ceiling tiles. The wood door to the room had louvers for ventilation.

2. Observation of storage room 1.120 was used to store surgical supplies. The room had soiled and stained carpet. Observation above the ceiling tiles revealed a black pipe, identified by Staff G to be a pipe from a toilet in a former bathroom on the floor above. The black pipe extended through the floor decking above the ceiling tiles. The door to the storage room had a 20 minute fire resistance rating.

An additional storage area attached to the same room was observed to have an open area 16 feet in length and one foot in width above the ceiling tiles. The open area was located in a wall that separated the storage area from a physician's office.

3. Observation above the ceiling tiles from a mechanical room with electrical equipment, revealed an open area approximately 22 feet long and 18 inches wide in the wall between the electrical room and a biomedical office, 1.124.

4. Observation of a mechanical room, 1.138, revealed penetrations surrounding multiple pipes and hot water lines.

5. Observation of two doors, one located on the "musak" room and the other located on the elevator hydraulic room revealed no fire resistance rating.

6. Observation of a mechanical room, formerly known as the boiler room, was noted to have a
door with nine panels of non-fire rated glass. The door had no fire resistance rating.

Observations were verified by Staff G and H present on the tour.

Based on review of facility schematics, facility observation and staff interview and verification, the facility failed to ensure that one hour fire rated construction with ? hour fire-rated doors in accordance with 8.4 protected hazardous areas. Doors were to be self-closing or automatic closing The facility had a census of eight patients at the time of the survey.

Findings included

Observation of the facility was conducted with Staff G and H on 09/17/13 between 1:30 P.M. and 4:45 P.M. The following storage areas were lacking appropriate fire rated construction

1. Observation of room G.027 revealed the door to the soiled utility room had no fire resistance rating and no self-closing or automatic closing device in place.

2. Observation above the ceiling tiles of storage area, G.068, revealed three penetrations located at a large duct.

3. Observation of storage room G.057 revealed two doors to the room. Both doors had no fire resistance rating and lacked self-closing or automatic closing devices. Observation above the ceiling tiles revealed an open area two feet wide by five feet long open to the deck above. Review of the facility schematic verified the room was to have a one hour fire rated construction.

Staff G and H present on the tour verified the observations.

Based on facility observation and staff interview and verification, the facility failed to ensure that exit access to the public way was maintained. One exit was affected. The facility had a census of 8 patients at the time of the survey.

Findings included;

On 09/17/13 at 10:25 A.M. observation with Staff G and H was conducted of an exit located in the waiting area of the Specialty Clinic. The exit discharge was noted to be through large double doors. Staff H verified the doors were once the main entrance to the facility.

Observation of the exit discharge revealed a concrete pad approximately ten feet wide. A sloped grassy area was observed off the concrete pad. A metal fence like barrier, approximately four feet in height, surrounded the grassy area and was designed to prevent anyone in the grassy area from falling from the sloped area. Travel to the public way, a parking lot, required travel in the uneven grassy area for approximately 60 feet. There was no gate in the metal fence once the paved parking lot was reached.

Staff G and H verified that upon exit from the building to the enclosed, uneven, grassy area, the paved parking lot could not be reached due to the fence.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency lighting of at least 1? hour duration was provided and that testing was conducted for 30 seconds per month. The facility had a census of 8 patients at the time of the survey.

Findings included;

Observation of the facility was conducted with Staff G and H on 09/16/13 between 10:55 A.M. and 3:40 P.M. and 09/17/13 between 8:35 A.M. and 4:45 P.M. The facility was noted to have emergency battery operated lighting at multiple areas of the facility. Staff G verified that testing of the battery operated emergency lighting was conducted.

On 09/19/13 at 1:05 P.M., review of facility testing documentation with Staff Z revealed that emergency lighting was noted as tested. There was no indication the monthly testing was for a period of 30 seconds and there was no indication of a 90 minute test annually. Staff Z verified that documentation did not reflect a 90 minute test per year or a test for 30 seconds per month.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency lighting of at least 1? hour duration was provided and that testing was conducted for 30 seconds per month. The facility had a census of 8 patients at the time of the survey.

Findings included;

Observation of the facility was conducted with Staff G and H on 09/17/13 between 8:35 A.M. and 4:45 P.M. The facility was noted to have emergency battery operated lighting at various areas of the facility. Staff G verified that testing of the battery operated emergency lighting was conducted.

On 09/19/13 at 1:05 P.M., review of facility testing documentation with Staff Z revealed that emergency lighting was noted as tested. There was no indication the monthly testing was for a period of 30 seconds and there was no indication of a 90 minute test annually. Staff Z verified that documentation did not reflect a 90 minute test per year or a test for 30 seconds per month.

Based on review of facility documentation and staff interview and verification, the facility failed to ensure that fire drills were held at unexpected times under varying conditions, at least quarterly on each shift. The facility had a patient census of eight patients at the time of the survey.

Findings included:

On 09/18/13 at 11:15 A.M , review of facility documentation was conducted with Staff G. Review of completed fire drills for the past 12 months revealed there was no documented evidence of a completed fire drill for the second quarter 2013, first shift and for the fourth quarter 2012, second shift.

Interview of Staff Z on 09/19/13 at 1:25 P.M. verified the documentation of the two fire drills was not available.

Based on facility observation and staff interview and verification, the facility failed to ensure that soiled linen receptacles did not exceed 32 gal (121 L) in capacity and that a capacity of 32 gal (121 L) was not exceeded within any 64 sq ft (5.9-sq m) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) were to be located in a room protected as a hazardous area when not attended. The facility had a census of eight patients at the time of the survey.

Findings included

Observation of the facility was conducted with Staff G and H on 09/16/13 between 10:55 A.M. and 3:40 P.M. and 09/17/13 between 8:35 A.M. and 4:45 P.M. Observation of an area on the first floor identified as the old emergency department entrance was noted to be the location of four large wheeled containers. The four large wheeled carts were full of bags of soiled linens and were stored at the entrance to the former emergency department.

Interview of Staff G revealed the area was the typical location for storage of the soiled linen containers until the contracted company picks up the soiled linens. Staff G further verified the location of the stored containers was not considered a hazardous storage area. The area was to be renovated in the future to be an acceptable storage area for the containers. Staff G and H verified the contracted company picks up the soiled linens about every two days.

NFPA 72
Chapter 7

7-3.2.1*
Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that detector sensitivity was tested every alternate year thereafter the one year installation After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

Findings included:

On 09/18/13 at 11:15 A.M. , review of facility documentation was conducted with Staff G. Review of completed testing information for the fire alarm and smoke detection systems revealed there was no documented evidence of smoke sensitivity testing since October 2009. Staff G verified the information.

On 09/19/13, at 2:40 P.M., Staff G provided information that indicated the smoke detector sensitivity had been tested that day. Staff G verified an oversight had occurred and the testing had not previously been completed.