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The facility failed to ensure the fire resistance rating of occupancy separation walls. 19.1.3.5, 8.2.1.3

Observation determined there were multiple unsealed openings around data cable penetrations in the two-hour fire resistant rated occupancy separation wall between the hospital and the attached clinic building.

Failure to ensure the fire resistance rating of occupancy separation walls as required increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) two-hour fire resistant rated occupancy separation wall in the facility.

The facility failed to ensure exit access was readily accessible at all times.

1) During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open. 7.2.1.4.3.1

Observation determined door #576 and door #577 opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened.

2) Means of egress must be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. The width of means of egress shall be measured in the clear at the narrowest point of the exit component under consideration. Exception: Projections not more than 4 1/2 in. (114 mm) on each side shall be permitted at 38 in. (965 mm) and below. 7.1.10.1, 7.3.2.2

Observation determined the handrails in the west swing bed corridor extended five and one half (5 ½) inches from the corridor wall and protruded into the exit corridor.

Failure to maintain the means of egress to be available at all times increases the risk of death or injury due to fire.

The deficiency affected egress from two (2) of two (2) smoke compartments in the facility.

The facility failed to ensure exit access was readily accessible at all times.

1) Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side. 7.2.1.5.3

Observation determined the south stairway door #687 was found to be secured with an access-controlled magnetic lock that required a code to be entered into a keypad or pushing a button on the wall to open the door. The door was not equipped with a delayed egress feature.

2) A latch or other fastening device on a door leaf shall be provided with a releasing device that has an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (865 mm) above the finished floor and not more than 48 in. (1220 mm) above the finished floor.

Observation determined the releasing mechanism for the latch on the east stairway door #687 was located 64 inches above the finished floor.

Failure to maintain the means of egress available at all times increases the risk of death or injury due to fire.

The deficiency affected egress from one (1) of two (2) smoke compartments in the facility.

Open space within the exit enclosure shall not be used for any purpose that has the potential to interfere with egress. 19.2.2.3, 7.2.2.5.3.1

The facility failed to keep exit enclosures free of obstructions.

Observation determined there was a table in the south stairway exit enclosure.

Failure to maintain exit enclosures free of obstructions increases the risk of death or injury due to fire.

The deficiency affected egress from one (1) of two (2) smoke compartments in the facility.

Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors must be enclosed with construction having a fire resistance of at least one hour. 19.3.1

The facility failed to ensure all vertical openings between floors were enclosed with construction having a fire resistance rating of at least one hour.

Observation determined there were multiple openings in the wall above door opening #6 in the east vertical separation wall in the basement.

Failure to protect vertical openings with construction having a fire resistance rating of at least one hour increases the risk of death or injury due to fire.

This deficiency affected one (1) of two (2) smoke compartments in the facility.

Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 19.3.2.1

The facility failed to ensure hazardous areas in fully sprinklered existing health care occupancies were separated from other spaces by smoke-resisting partitions and latching doors.

Observation determined:

1) The ceiling in the Record Storage Room had two (2) unsealed openings.

2) The ceiling in Linen Room #22 had an unsealed pipe penetration.

3) The corridor door to Storage Room #22 failed to latch into the frame.

Failure to ensure hazardous areas are separated from other spaces by smoke-resisting partitions and latching doors increases the risk of death or injury due to fire.

The deficiency affected three (3) of numerous hazardous areas in the facility.

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

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

Fire alarm system batteries shall be subjected to a load voltage test semiannually. NFPA 72, 14.4.2.2 item 5(e).

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. A load voltage test of the fire alarm system batteries was done during the annual inspection by an outside company on 03/22/2016. Records did not indicate any other load voltage test on the fire alarm system batteries in the past year.

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. The fire alarm system 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, 9.6.2.10.1.1, NFPA 72 17.7.4.1.

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

Observation determined twenty (20) smoke detectors throughout the facility were installed within 3 ft. of an air supply diffuser or return air opening.

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

This deficiency affected twenty (20) of numerous smoke detectors in the facility. The smoke detection system serves the entire facility.

Health care facilities shall be protected throughout by an approved, supervised automatic fire sprinkler system. 19.3.5.3, 19.3.5.4, 9.7.1.1(1), NFPA 13

The facility failed to install the automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

Observation determined:

1) The elevator pit for the hydraulically operated elevator lacked sprinklers in the bottom of the elevator shaft.

2) Two (2) sprinklers in the Laundry Room were green bulb sprinklers indicating intermediate temperature rated sprinklers. No evidence was available to indicate the temperature at the ceiling in the room exceeded 100 degrees.

3) One (1) sprinkler in Walk-in Freezer #1 and one (1) sprinkler in the Walk-in Freezer #2 were of ordinary-temperature classification. The walk-in freezers were equipped with an automatic defrosting feature. NFPA 13 requires sprinklers to be intermediate-rated sprinklers in automatic defrosting walk-in freezers.

4) Two (2) sprinklers in the Laundry Room were closer than the minimum of six feet apart.

Failure to install and maintain the automatic sprinkler system in accordance with NFPA 13 increases the risk of injury and death due to fire.

The deficiency affected sprinkler coverage in four (4) of numerous locations in the facility. The automatic sprinkler system serves the entire facility.

Automatic sprinkler systems are continously maintained in reliable operating condition and are inspected and tested periodically. The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. 19.7.6, 4.6.12, NFPA 25

A main drain test shall be conducted annually at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves. In systems where the sole water supply is through a backflow preventer and/or pressure reducing valves, the main drain test of at least one system downstream of the device shall be conducted on a quarterly basis. NFPA 25, 13.2.5, 13.2.5.1

All backflow preventers installed in fire protection system piping shall be tested annually by conducting a forward flow test of the system at the designed flow rate, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer. NFPA 25, 13.6.2.1

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25.

Record review determined:

1) Quarterly flow tests of the automatic sprinkler system were not completed as required. Records did not indicate a flow test was done during the second quarter of 2016.

2) No annual back flow preventer test was conducted in the past twelve months.

Failure to inspect, test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

The deficiency affected the complete automatic sprinkler system, which serves the entire facility.

Fire extinguishers provided for the protection of cooking appliances that use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires. A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be actuated prior to using the fire extinguisher. 19.3.5.12, 9.7.4.1, NFPA 10, 5.5.5, 5.5.5.3

The facility failed to inspect portable fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Observation determined the facility failed to post an operational sign at the location of the Class K fire extinguisher.

Failure to ensure portable fire extinguishers comply with NFPA 10 increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous portable fire extinguishers in the facility.

Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. 19.3.6.1, 19.3.6.1(1)

Smoke compartments protected throughout by an approved supervised automatic sprinkler system shall be permitted to have spaces that are unlimited in size and open to the corridor, provided that all of the following criteria are met:
a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers.
c) The open space is protected by an electrically supervised automatic smoke detection system or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses station or similar space.
d) The space does not obstruct access to required exits.

The facility failed to separate other areas from corridors in accordance with 19.3.6.1.

Observation determined the Basement Vending Room without a door separating the room from the corridor did not have automatic smoke detection and was not located to allow direct supervision by the facility staff from a nurses' station or similar space.

Failure to separate corridors from other areas in accordance with 19.3.6.1 increases the risk of death or injury due to fire.

This deficiency affected one (1) of numerous exit corridors in the facility.

Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. 19.3.6.3.5

The facility failed to ensure corridor doors latched into their frames and resisted the passage of smoke.

Observation determined the east corridor door to the Kitchen failed to latch into the frame.

Failure to ensure corridor doors latch properly increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous corridor doors in the facility.

Smoke barriers shall be constructed in accordance with Section 8.5 and shall have a minimum one-half hour fire resistance rating. 19.3.7.3

The facility failed to ensure one (1) of one (1) smoke barrier was at least one-half hour fire resistant and smoke resistant.

Observation determined two (2) duct and multiple cable penetrations had openings that were not sealed with fire rated materials.

Failure to maintain smoke barriers as required increases the risk of death or injury due to fire.

The deficiency affected two (2) of two (2) smoke compartments in the building.

The facility failed to ensure electrical wiring and electrical equipment met the requirements of NFPA 70, National Electrical Code. 19.5.1.1, 9.1.2

Observation determined:

1) There was an electric heat tape attached to the condensate drain line in Walk-in Freezer #1. The heat tape wiring had the insulation removed and exposed wiring was connected with wire nuts.

2) There was an extension cord that extended through the ceiling in Walk-in Freezer #2 to provide power to an electric heat tape.

3) There was exposed wiring to the fan in Walk-in Freezer #2 that was connected with wire nuts.

Failure to ensure electrical wiring is in accordance with NFPA 70 increases the risk of death or injury due to fire.

The deficiency affected two (2) of numerous areas in the facility.

A written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire
19.7.2.2

The facility failed to provide a fire safety plan as required.

Observation and policy review determined the fire safety plan did not provide for the emergency phone call to fire department as required.

Failure to provide a fire plan as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of nine (9) required fire safety plan provisions for the facility.

Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110. Critical care rooms (Category 1 Room) shall be served only by a Type I EES. General care rooms (Category 2 Room) shall be served by a Type I or Type II EES. A Type I EES serving a critical care room (Category 1 Room) shall be permitted to serve general care rooms (Category 2 Room) in the same facility. NFPA 99, 6.3.2.2.10, NFPA 110, 5.6.5.6, 5.6.5.6.1

The facility failed to ensure the emergency generator was in compliance with NFPA 99, Health Care Facilities Code and NFPA 110, Standard for Emergency and Standby Power Systems.

All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. The remote manual stop station shall be labeled.

Observation determined there was no remote stop switch for the Basement Generator located outside of the generator room.

Failure to ensure the emergency generator was in compliance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

The deficiency affected one (1) of two (2) emergency generators which provides all emergency power and emergency lighting to the facility.