HospitalInspections.org

Based on observation, the facility failed to assure a corridor door would latch per NFPA 101, 2000 Edition, Section This deficiency affects 1 of 3 lower level smoke compartments.

Findings include:

During an observation on 9/29/15 at 9:15 a.m., the exit corridor door to the "Shell Space" storage room did not latch when exercised at least three times. The door had a self closure device.

Based on observation and interview, the facility failed to ensure all vertical openings containing stairs and a penthouse were properly enclosed with 1 hour rated doors and other rated construction in accordance with NFPA 80, 1999 Edition, Section 11-1.2.1, and NFPA 101, 2000 Edition, Section 18.3.1.1. This deficiency had the potential to affect 3 of 5 total smoke compartments (including the main level and the lower levels).

Findings include:

1. During an observation on 9/29/15 at 9:09 a.m., the stairwell connecting the east zones of the lower and upper levels and, serving the "communicating stairway" between the levels, were made of glass walls and door enclosures with metal framing. The glass structures at the main and the lower level were not of 1-hour fire rating for the vertical separation.¹

2. During an observation on 9/29/15 at 9:50 a.m., the controlled access door from the penthouse to the housekeeping room on the main level was found open. Staff member A, CEO, stated the door was hard to open and usually was left open.²

¹ NFPA 101, 2000 Edition, Section 18.3.1.1, Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least two hours connecting four stories or more. (One hour for single story building and sprinklered buildings up to three stories in height.)

² NFPA 80 Standard for Fire Doors and Fire Windows, 1999 Edition, Section 11-1.2.1;
Access doors shall be self-closing.

Based on observation and interview, the facility failed to ensure proper door hold open devices were utilized of corridor doors with self closure devices per NFPA 101, Sections 18.2.2.2.6 and Annex A.18.2.2.2.6. This deficiency may affect 3 of 3 lower level smoke compartments.

Findings include:

1. During an observation on 9/29/15 at 8:59 a.m., the exit corridor door to the Physicial Therapy department was held open with a rubber wedge (not an automatic release device.) The door had a self closure device. An unidentified physical therapy staff member stated the door was held open in this manner during the hours of operation.¹ ²

2. During an observation on 9/29/15 at 9:31 a.m., the exit corridor door to the housekeeping storage room on the lower level had a knock-down type door stopper (not an automatic release device) installed on the lower part of the door. The door stopper had to be lifted up by one's foot in order to close the door. The door had a self closure device.¹ ²

3. During the observations on 9:29/15 at 9:40 p.m., the exit corridor doors to the Central Supply and the Central Suppy Office had knock-down type door stoppers (not an automatic release devices.) Both of the doors had self-closures.¹ ²

4. During an observation on 9/29/15 at 10:11 a.m., the exit corridor door to the "Ortho Supply" room was held open with a rubber wedge (not an automatic release device.) The door had a self closure device.¹ ²

¹ NFPA 101, 2000 Edition, Section 18.2.2.2.6; Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure (except boiler rooms, heater rooms, and mechanical equipment rooms) 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 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.

² NFPA 101, 2000 Edition, Annex A.18.2.2.2.6; It is desirable to keep doors in exit passageways, stair enclosures, horizontal exits, smoke barriers, and required enclosures around hazardous areas closed at all times to impede the travel of smoke and fire gases. Functionally, however, this involves decreased efficiency and limits patient observation by the staff of an institution. To accommodate such needs, it is practical to presume that such doors will be kept open, even to the extent of employing wood chocks and other makeshift devices. Doors in exit passageways, horizontal exits, and smoke barriers should, therefore, be equipped with automatic hold-open devices activated by the methods described, regardless of whether the original installation of the doors was predicated on a policy of keeping them closed.

Based on observation and interview, the facility failed to maintain the smoke resistance rating of barriers in accordance with NFPA 101, 2000 Edition, Section 8.3.6.1. The deficiency could affect the occupants in 2 of 3 lower level smoke compartments.

Findings include:

During an observation on 9/29/15 at 2:05 p.m., a 3-inch thick conduit was penetrating the smoke barrier above the double doors near the Information Technology (IT) room. The conduit was partially filled (only 1/3) with a combination of fire chalking and fire rated expandable foam. The conduit was open on both sides of the smoke barrier. Staff member B, facility manager, who accompanied the surveyor, stated the conduit penetration needed more fire rated expandable foam.¹

¹ NFPA 101, 2000 Edition, Section 8.3.6.1, Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows: (1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions: a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on record review and interview, the facility failed to conduct fire drills at a minimum of quarterly on each shift per NFPA 101, 2000 Edition, Section 18.7.1.2. This deficiency could affect all of the occupants in 4 of 5 (excluding the clinic employees and patients) smoke compartments.

Findings include:

Review of facility fire drill documents reflected fire drills were not conducted during second shifts (6:00 p.m. to 6:00 a.m.) during the 4th quarter of 2014, and during the first and second quarters of 2015. Fire drills are required to be conducted at least quarterly on all shifts.¹

During an interview on 9/29/15 at 11:00 a.m., staff member B, facility manager, stated he knew they were running behind on conducting drills.

¹ NFPA 101, 2000 Edition, Section 18.7.1.2; Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based on observation and interview, the facility failed to test smoke detectors and provide a hard copy record per NFPA 72, 1999 Edition, Sections 7-3.2.1 and 7-5.2. This deficiency could affect 5 of 5 smoke compartments.

Findings include:

Review of the facility's maintenance documents reflected a lack of the most recent smoke detector sensitivity testing records.

The sensitivity testing of the smoke detectors is required on alternate years unless previous testing shows the detectors have remained within their listed and marked sensitivity ranges. The interval between testing may then be extended to 5 years. There were no records, at the time of the survey, indicating the smoke detectors met this requirement or the alternate year testing.¹ The facility must have a printed copy of the sensitivity testing documents for review for the Authority Having Jurisdiction.²

During an interview on 9/29/15 at 1:15 p.m., staff member B, facility manager, stated according to the vendor, the system was not able to print the sensitivity reports. However, according to the EST International Intelligent Photoelectric Smoke Detector, manufacturer's record, provided by the facility, "The results of the self-check are automatically updated and permanently stored in the detector's non-volatile memory. This information is accessible for review any time at the control panel, PC, or by using the SIGA-PRO Signature Program/Service Tool."

¹ NFPA 72 National Fire Alarm Code, 1999 Edition, Section 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.

² NFPA 72, 1999 Edition, Section 7-5.2-2; A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) * Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Based on observations and interview, the facility failed to maintain components of the sprinkler system in accordance with NFPA 13, 1998 Edition, Section 5-1.1. These deficiencies could affect 2 of 3 lower level smoke compartments.

Findings include:

1. During an observation on 9/29/25 at 8:54 a.m., a gap between the sprinkler escutcheon ring and the ceiling tile surface was found in the Janitorial Closet on the southwest corner of the lower level.¹

2. During an observation on 9/29/15 at 9:32 a.m., the ceiling tiles in the IT room (lower level) was missing sections and were damaged. The sprinklers were installed below the ceiling tiles.¹

3. During an observation on 9/29/15 at 9:36 a.m., one ceiling tile was missing in the maintenance office.¹

During an interview on 9/29/15 at 9:38 a.m., staff member B, facility manager, stated the tile was missing for a month since a new Johnson's Control system was installed for nursing.¹

4. During an observation on 9/29/15 at 10:24 a.m., a sprinkler head was missing an escutcheon ring in the Ultrasound restroom on the main level.²

¹ NFPA 13 Standard for the Installation of Sprinkler Systems 1999 Edition, Section 5-1.1; The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5-6.4.1, 5-7.4.1, 5-8.4.1, 5-9.4.1, 5-10.4.1, and 5-11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.

² NFPA 13, 1999 Edition, Section 3-2.7.2; Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

Based on observations, the facility failed to inspect all portable fire extinguishers at least every 30 days in accordance with NFPA 10, 1998 Edition, Section 4-3.1, affecting 5 of 5 smoke compartments. Additionally, facility failed to ensure portable fire extinguishers were mounted in accordance with NFPA 10, 1998 Edition, Section 4-3.2, affecting 1 of 3 lower level smoke compartments.

Findings include:

1. During an observation on 9/29/15 at 8:57 a.m., a fire extinguisher in the elevator equipment room (lower level) was tagged with a monthly inspection tag. The tag was completely blank, indicating missing monthly inspections. According to the tag, the unit was recharged in November of 2014 by the vendor. Throughout the inspection of the building including both the lower and the main levels, none of the fire extinguishers were inspected monthly.¹

2. During an observation on 9/29/15 at 1:11 p.m., a fire extinguisher was noticed hanging behind a large shelf unit, a tall cardboard box and several floor maps. The unit was not clearly visible from all directions.²

¹ NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 4-3.1 Frequency; Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

² NFPA 10, 1998 Edition, Section 4-3.2; Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility

Based on observations and interview, the facility failed to maintain the width of an exit corridor in accordance with NFPA 101, 2000 Edition, Section 18.2.3.3 and 7.4.1.1. These deficiencies could affect 2 of 3 lower level smoke compartments.

Findings include:

1. During an observation on 9/29/15 at 9:10 a.m., two vending machines were placed in the exit corridor leading to the clinic near the stairway on the lower level.¹

2. During an observation on 9/29/15 at 9:29 a.m., the Maintenance and the IT corridors contained storage of large bins of recycle, buckets, medical equipment, water bottles and storage carts.¹

During an interview on 9/29/15 at 11:15 a.m., staff member B, facility manager, stated these corridors were thought to be exempt from the code requirements due to low hospital patient traffic in the lower level.²

¹ NFPA 101, 2000 Edition, Section 18.2.3.3, Aisles, corridors, and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (2.4 m) in clear and unobstructed width. Where ramps are used as exits, see 18.2.2.6.

² NFPA 101, 2000 Edition, Section 7.4.1.1; The number of means of egress from any balcony, mezzanine, story, or portion thereof shall be not less than two.
Exception: This requirement shall not apply where a single means of egress is permitted in Chapters 11 through 42.
Exception: A mezzanine or balcony shall be permitted to have a single means of egress, provided that the common path of travel limitations of Chapters 12 through 42 are met.

Based on interview and record review, the facility failed to conduct monthly load tests on its generators per NFPA 99, 1999 Edition, Sections 3-4.4.1.1 and 3-4.4.2, and NFPA 110, 1999 Edition, Section 6-4.1. This deficiency could affect all five smoke compartments.

Findings include:

Review of the generator maintenance records showed the generator was not exercised under load on a monthly basis. During an interview on 9/29/15 at 10:55 a.m., staff member B, facility manager, stated he was not conducting monthly load tests on the generators. The facility had two generators. Staff member B stated he ran the generators weekly for 20 minutes but not under load.¹ ² ³

Review of the generator maintenance contractor reports also showed the contractor was not authorized to transfer load when they completed inspection tests on the generators in April of 2015.

¹ NFPA 99 Standards for Health Care Facilities, 1999 Edition, Section 3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches; (a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1. * Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.

² NFPA 99, 1999 Edition, Section 3-4.4.2 Recordkeeping; A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

3 NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition, Section 6-4.1; Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
Annex A-6-4-1 should be referenced for the type of weekly items that should be reviewed or the manufacturer recommendations should be used.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC and NFPA 70, 1999 Edition, Article 110-26. These deficiencies could affect 2 of 5 smoke compartments.

Findings include:
1. During an observation on 9/29/15 at 9:01 a.m., access to the electrical panel marked as LN4L in physical therapy was blocked by storage of a utility cart and pillows directly in front of it.¹

2. During an observation on 9/29/15 at 9:19 a.m., a refrigerator and a microwave were plugged into a power strip in the Sleep Quarters in the lower level.²

3. During an observation on 9/29/15 at 10:06 a.m., a microwave was plugged into a power strip in the nurses' lounge on the main floor.²

4. During an observation on 9/29/15 at 10:30 a.m., access to two electrical panels (MC2L and MN2L) were blocked by storage of multiple items directly in front of the panels in the LAB storage room. Additionally, a microwave was plugged into a power strip in this same room.¹

5. During an observation on 9/29/15 at 10:36 a.m., a microwave was plugged into an adaptor in the business office on the main floor.²

6. During an observation on 9/29/15 at 10:39 a.m., a microwave was plugged into a power strip in the Counseling room on the main floor. Additionally, the power strip was wedged between the microwave and wall.²

¹ NFPA 70 National Electrical Code, 1999 Edition, Article 110-26; Sufficient working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Area required is three feet deep in front of equipment and 30 inches wide or the width of the equipment from live parts is required to be maintained if exposed. Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

² CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

Based on observation, the facility failed to assure a corridor door would latch per NFPA 101, 2000 Edition, Section This deficiency affects 1 of 3 lower level smoke compartments.

Findings include:

During an observation on 9/29/15 at 9:15 a.m., the exit corridor door to the "Shell Space" storage room did not latch when exercised at least three times. The door had a self closure device.

Based on observation and interview, the facility failed to ensure all vertical openings containing stairs and a penthouse were properly enclosed with 1 hour rated doors and other rated construction in accordance with NFPA 80, 1999 Edition, Section 11-1.2.1, and NFPA 101, 2000 Edition, Section 18.3.1.1. This deficiency had the potential to affect 3 of 5 total smoke compartments (including the main level and the lower levels).

Findings include:

1. During an observation on 9/29/15 at 9:09 a.m., the stairwell connecting the east zones of the lower and upper levels and, serving the "communicating stairway" between the levels, were made of glass walls and door enclosures with metal framing. The glass structures at the main and the lower level were not of 1-hour fire rating for the vertical separation.¹

2. During an observation on 9/29/15 at 9:50 a.m., the controlled access door from the penthouse to the housekeeping room on the main level was found open. Staff member A, CEO, stated the door was hard to open and usually was left open.²

¹ NFPA 101, 2000 Edition, Section 18.3.1.1, Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least two hours connecting four stories or more. (One hour for single story building and sprinklered buildings up to three stories in height.)

² NFPA 80 Standard for Fire Doors and Fire Windows, 1999 Edition, Section 11-1.2.1;
Access doors shall be self-closing.

Based on observation and interview, the facility failed to ensure proper door hold open devices were utilized of corridor doors with self closure devices per NFPA 101, Sections 18.2.2.2.6 and Annex A.18.2.2.2.6. This deficiency may affect 3 of 3 lower level smoke compartments.

Findings include:

1. During an observation on 9/29/15 at 8:59 a.m., the exit corridor door to the Physicial Therapy department was held open with a rubber wedge (not an automatic release device.) The door had a self closure device. An unidentified physical therapy staff member stated the door was held open in this manner during the hours of operation.¹ ²

2. During an observation on 9/29/15 at 9:31 a.m., the exit corridor door to the housekeeping storage room on the lower level had a knock-down type door stopper (not an automatic release device) installed on the lower part of the door. The door stopper had to be lifted up by one's foot in order to close the door. The door had a self closure device.¹ ²

3. During the observations on 9:29/15 at 9:40 p.m., the exit corridor doors to the Central Supply and the Central Suppy Office had knock-down type door stoppers (not an automatic release devices.) Both of the doors had self-closures.¹ ²

4. During an observation on 9/29/15 at 10:11 a.m., the exit corridor door to the "Ortho Supply" room was held open with a rubber wedge (not an automatic release device.) The door had a self closure device.¹ ²

¹ NFPA 101, 2000 Edition, Section 18.2.2.2.6; Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure (except boiler rooms, heater rooms, and mechanical equipment rooms) 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 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.

² NFPA 101, 2000 Edition, Annex A.18.2.2.2.6; It is desirable to keep doors in exit passageways, stair enclosures, horizontal exits, smoke barriers, and required enclosures around hazardous areas closed at all times to impede the travel of smoke and fire gases. Functionally, however, this involves decreased efficiency and limits patient observation by the staff of an institution. To accommodate such needs, it is practical to presume that such doors will be kept open, even to the extent of employing wood chocks and other makeshift devices. Doors in exit passageways, horizontal exits, and smoke barriers should, therefore, be equipped with automatic hold-open devices activated by the methods described, regardless of whether the original installation of the doors was predicated on a policy of keeping them closed.

Based on observation and interview, the facility failed to maintain the smoke resistance rating of barriers in accordance with NFPA 101, 2000 Edition, Section 8.3.6.1. The deficiency could affect the occupants in 2 of 3 lower level smoke compartments.

Findings include:

During an observation on 9/29/15 at 2:05 p.m., a 3-inch thick conduit was penetrating the smoke barrier above the double doors near the Information Technology (IT) room. The conduit was partially filled (only 1/3) with a combination of fire chalking and fire rated expandable foam. The conduit was open on both sides of the smoke barrier. Staff member B, facility manager, who accompanied the surveyor, stated the conduit penetration needed more fire rated expandable foam.¹

¹ NFPA 101, 2000 Edition, Section 8.3.6.1, Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows: (1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions: a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. b) It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on record review and interview, the facility failed to conduct fire drills at a minimum of quarterly on each shift per NFPA 101, 2000 Edition, Section 18.7.1.2. This deficiency could affect all of the occupants in 4 of 5 (excluding the clinic employees and patients) smoke compartments.

Findings include:

Review of facility fire drill documents reflected fire drills were not conducted during second shifts (6:00 p.m. to 6:00 a.m.) during the 4th quarter of 2014, and during the first and second quarters of 2015. Fire drills are required to be conducted at least quarterly on all shifts.¹

During an interview on 9/29/15 at 11:00 a.m., staff member B, facility manager, stated he knew they were running behind on conducting drills.

¹ NFPA 101, 2000 Edition, Section 18.7.1.2; Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Based on observation and interview, the facility failed to test smoke detectors and provide a hard copy record per NFPA 72, 1999 Edition, Sections 7-3.2.1 and 7-5.2. This deficiency could affect 5 of 5 smoke compartments.

Findings include:

Review of the facility's maintenance documents reflected a lack of the most recent smoke detector sensitivity testing records.

The sensitivity testing of the smoke detectors is required on alternate years unless previous testing shows the detectors have remained within their listed and marked sensitivity ranges. The interval between testing may then be extended to 5 years. There were no records, at the time of the survey, indicating the smoke detectors met this requirement or the alternate year testing.¹ The facility must have a printed copy of the sensitivity testing documents for review for the Authority Having Jurisdiction.²

During an interview on 9/29/15 at 1:15 p.m., staff member B, facility manager, stated according to the vendor, the system was not able to print the sensitivity reports. However, according to the EST International Intelligent Photoelectric Smoke Detector, manufacturer's record, provided by the facility, "The results of the self-check are automatically updated and permanently stored in the detector's non-volatile memory. This information is accessible for review any time at the control panel, PC, or by using the SIGA-PRO Signature Program/Service Tool."

¹ NFPA 72 National Fire Alarm Code, 1999 Edition, Section 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.

² NFPA 72, 1999 Edition, Section 7-5.2-2; A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) * Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Based on observations and interview, the facility failed to maintain components of the sprinkler system in accordance with NFPA 13, 1998 Edition, Section 5-1.1. These deficiencies could affect 2 of 3 lower level smoke compartments.

Findings include:

1. During an observation on 9/29/25 at 8:54 a.m., a gap between the sprinkler escutcheon ring and the ceiling tile surface was found in the Janitorial Closet on the southwest corner of the lower level.¹

2. During an observation on 9/29/15 at 9:32 a.m., the ceiling tiles in the IT room (lower level) was missing sections and were damaged. The sprinklers were installed below the ceiling tiles.¹

3. During an observation on 9/29/15 at 9:36 a.m., one ceiling tile was missing in the maintenance office.¹

During an interview on 9/29/15 at 9:38 a.m., staff member B, facility manager, stated the tile was missing for a month since a new Johnson's Control system was installed for nursing.¹

4. During an observation on 9/29/15 at 10:24 a.m., a sprinkler head was missing an escutcheon ring in the Ultrasound restroom on the main level.²

¹ NFPA 13 Standard for the Installation of Sprinkler Systems 1999 Edition, Section 5-1.1; The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5-6.4.1, 5-7.4.1, 5-8.4.1, 5-9.4.1, 5-10.4.1, and 5-11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.

² NFPA 13, 1999 Edition, Section 3-2.7.2; Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

Based on observations, the facility failed to inspect all portable fire extinguishers at least every 30 days in accordance with NFPA 10, 1998 Edition, Section 4-3.1, affecting 5 of 5 smoke compartments. Additionally, facility failed to ensure portable fire extinguishers were mounted in accordance with NFPA 10, 1998 Edition, Section 4-3.2, affecting 1 of 3 lower level smoke compartments.

Findings include:

1. During an observation on 9/29/15 at 8:57 a.m., a fire extinguisher in the elevator equipment room (lower level) was tagged with a monthly inspection tag. The tag was completely blank, indicating missing monthly inspections. According to the tag, the unit was recharged in November of 2014 by the vendor. Throughout the inspection of the building including both the lower and the main levels, none of the fire extinguishers were inspected monthly.¹

2. During an observation on 9/29/15 at 1:11 p.m., a fire extinguisher was noticed hanging behind a large shelf unit, a tall cardboard box and several floor maps. The unit was not clearly visible from all directions.²

¹ NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 4-3.1 Frequency; Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

² NFPA 10, 1998 Edition, Section 4-3.2; Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility

Based on observations and interview, the facility failed to maintain the width of an exit corridor in accordance with NFPA 101, 2000 Edition, Section 18.2.3.3 and 7.4.1.1. These deficiencies could affect 2 of 3 lower level smoke compartments.

Findings include:

1. During an observation on 9/29/15 at 9:10 a.m., two vending machines were placed in the exit corridor leading to the clinic near the stairway on the lower level.¹

2. During an observation on 9/29/15 at 9:29 a.m., the Maintenance and the IT corridors contained storage of large bins of recycle, buckets, medical equipment, water bottles and storage carts.¹

During an interview on 9/29/15 at 11:15 a.m., staff member B, facility manager, stated these corridors were thought to be exempt from the code requirements due to low hospital patient traffic in the lower level.²

¹ NFPA 101, 2000 Edition, Section 18.2.3.3, Aisles, corridors, and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (2.4 m) in clear and unobstructed width. Where ramps are used as exits, see 18.2.2.6.

² NFPA 101, 2000 Edition, Section 7.4.1.1; The number of means of egress from any balcony, mezzanine, story, or portion thereof shall be not less than two.
Exception: This requirement shall not apply where a single means of egress is permitted in Chapters 11 through 42.
Exception: A mezzanine or balcony shall be permitted to have a single means of egress, provided that the common path of travel limitations of Chapters 12 through 42 are met.

Based on interview and record review, the facility failed to conduct monthly load tests on its generators per NFPA 99, 1999 Edition, Sections 3-4.4.1.1 and 3-4.4.2, and NFPA 110, 1999 Edition, Section 6-4.1. This deficiency could affect all five smoke compartments.

Findings include:

Review of the generator maintenance records showed the generator was not exercised under load on a monthly basis. During an interview on 9/29/15 at 10:55 a.m., staff member B, facility manager, stated he was not conducting monthly load tests on the generators. The facility had two generators. Staff member B stated he ran the generators weekly for 20 minutes but not under load.¹ ² ³

Review of the generator maintenance contractor reports also showed the contractor was not authorized to transfer load when they completed inspection tests on the generators in April of 2015.

¹ NFPA 99 Standards for Health Care Facilities, 1999 Edition, Section 3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches; (a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1. * Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.

² NFPA 99, 1999 Edition, Section 3-4.4.2 Recordkeeping; A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

3 NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition, Section 6-4.1; Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
Annex A-6-4-1 should be referenced for the type of weekly items that should be reviewed or the manufacturer recommendations should be used.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC and NFPA 70, 1999 Edition, Article 110-26. These deficiencies could affect 2 of 5 smoke compartments.

Findings include:
1. During an observation on 9/29/15 at 9:01 a.m., access to the electrical panel marked as LN4L in physical therapy was blocked by storage of a utility cart and pillows directly in front of it.¹

2. During an observation on 9/29/15 at 9:19 a.m., a refrigerator and a microwave were plugged into a power strip in the Sleep Quarters in the lower level.²

3. During an observation on 9/29/15 at 10:06 a.m., a microwave was plugged into a power strip in the nurses' lounge on the main floor.²

4. During an observation on 9/29/15 at 10:30 a.m., access to two electrical panels (MC2L and MN2L) were blocked by storage of multiple items directly in front of the panels in the LAB storage room. Additionally, a microwave was plugged into a power strip in this same room.¹

5. During an observation on 9/29/15 at 10:36 a.m., a microwave was plugged into an adaptor in the business office on the main floor.²

6. During an observation on 9/29/15 at 10:39 a.m., a microwave was plugged into a power strip in the Counseling room on the main floor. Additionally, the power strip was wedged between the microwave and wall.²

¹ NFPA 70 National Electrical Code, 1999 Edition, Article 110-26; Sufficient working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Area required is three feet deep in front of equipment and 30 inches wide or the width of the equipment from live parts is required to be maintained if exposed. Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

² CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.