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Based on observation, the facility failed to maintain doors in an exit passageway. This was evidenced by smoke barrier doors that were held-open with unapproved devices. This affected two of nine smoke compartments, and could result in the inability to contain smoke and/or fire to a smoke compartment.

Findings:

During a tour of the facility with staff on 6/20/17, the cross corridor smoke barrier doors were observed.

At 2:15 p.m., the Emergency Room (ER) corridor doors were observed. The double set of cross corridor doors in the smoke barrier wall located next to the Laboratory were equipped with self-closing devices. The south left leaf door was observed held-open by a wooden wedge that was placed at the bottom of the door. The doors were not equipped with approved hold-open devices that were interfaced with the fire alarm system.

Based on observation and interview, the facility failed to maintain the emergency lightings. This was evidenced by an emergency battery back-up lighting unit that failed when tested. This affected one of nine smoke compartments, and could result in a potential delay in evacuation with a loss of lighting during a power outage.

NFPA 101, Life Safety Code, 2012 Edition.
7.9.3 Periodic Testing of Emergency Lighting Equipment.

7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.

7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility and interview with staff on 6/20/17, the emergency light units were observed.

At 3 p.m., an emergency battery back-up lighting unit at the Emergency Room Nursing Station failed when tested. Upon interview, Staff 5 confirmed the finding.

Based on observation, the facility failed to maintain the hazardous areas. This was evidenced by a hazardous area enclosure opening not equipped with a self-closing device on the door and unsealed ceiling penetration. This affected two of nine smoke compartments, and could result in a delay in containing smoke and/or fire to a hazardous area.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.2 Protection from Hazards.
19.3.2.1.3 The doors shall be self-closing or automatic-closing.
19.3.2.1.5 Hazardous areas shall include, but shall not be restricted
to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal
(242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including
repair shops, used for storage of combustible supplies and
equipment in quantities deemed hazardous by the authority
having jurisdiction
(8) Laboratories employing flammable or combustible materials
in quantities less than those that would be considered
a severe hazard
Findings:

During a facility tour with staff on 6/20/17, the hazardous areas were observed.

1. At 2:40 p.m., the Laboratory ceiling were observed. There were two approximately one inch diameter penetrations with metal conduits traveling through the ceiling above the Bio-Hazard refrigerator.


2. At 3:10 p.m., the Basement Storage Room was observed. The room was greater than 50 square feet ( approximately 450 square feet) and was fully sprinklered. The room had multiple combustible boxes. The corridor door was not equipped with a self-closing device.

Based on observation, document review, and interview, the facility failed to maintain the cooking facilities. This was evidenced by missing a semi-annual basis hood cleaning record.
This affected one of nine smoke compartments, and could potentially result in the uncontrolled spread of a grease fire in the cooking area.

NFPA 101. Life Safety Code, 2012 Edition
19.3.2.5 Cooking Facilities.
19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3
9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition
Chapter 11 Procedures for the Use, Inspection,
Testing, and Maintenance of Equipment
11.4* Inspection for Grease Buildup. The entire exhaust system
shall be inspected for grease build up by a properly trained,
qualified, and certified person(s) acceptable to the authority having
jurisdiction and in accordance with Table 11.4.
Table 11.4 Schedule of Inspection for Grease Buildup
Type or Volume
of Cooking
Inspection
Frequency
Systems serving solid fuel cooking
operations
Monthly
Systems serving high-volume cooking
operations, such as 24-hour cooking,
char-broiling, or wok cooking
Quarterly
Systems serving moderate-volume cooking
operations
Semiannually
Systems serving low-volume cooking
operations, such as churches, day camps,
seasonal businesses, or senior centers
Annually

Findings:

During a facility tour, document review, and interview with staff on 6/20/17, the kitchen hood was observed and service records were requested.

At 9:15 a.m., the Dietary cooking area was observed. The range hood did not have a cleaning sticker in-place. No documentation was available for a current or previous bi-annual hood cleaning and service. Upon interview, Staff 2 confirmed the finding.

Based on observation, the facility failed to maintain the fire alarm system. This was evidenced by a fire alarm circuit disconnecting means that was not distinctly marked red. This affected nine of nine smoke compartments, and could result in a delay in identifying the proper circuit during an electrical emergency.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72 National Fire Alarm and signaling Code, 2010 edition
Chapter 10 Fundamentals
10.1 Application.
10.1.1 The basic functions of a complete fire alarm or signaling
system shall comply with the requirements of this chapter.
10.1.2 The requirements of this chapter shall apply to systems,
equipment, and components addressed in Chapters 12,
14, 17, 18, 21, 23, 24, 26 and 27.
10.2 Purpose. The purpose of fire alarm and signaling systems
shall be primarily to provide notification of alarm, supervisory,
and trouble conditions; to alert the occupants; to summon
aid; and to control emergency control functions.
10.5.5.2 Circuit Identification and Accessibility.
10.5.5.2.1 The location of the dedicated branch circuit disconnecting
means shall be permanently identified at the control unit.
10.5.5.2.2 For fire alarm systems the circuit disconnecting means shall be identified as "FIRE ALARM CIRCUIT."
10.5.5.2.3 For fire alarm systems the circuit disconnecting means shall have a red marking.
10.5.5.2.4 The circuit disconnecting means shall be accessible only to authorized personnel.

Findings:

During a facility tour with staff on 6/20/17, the fire alarm system electrical circuit was observed.

At 3:20 p.m., there was no distinct red marking on or beside the identified Fire Alarm Control Panel (FACP) circuit breaker switch 3, located in the ELS Electrical Panel.

Based on observation, document review, and interview, the facility failed to maintain the fire alarm system (FAS). This was evidenced by failure to perform a semi-annual FAS inspection. This affected nine of nine smoke compartments, and could result in a system malfunction or, delay in notification in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1* General.
9.6.1.5* To ensure operational integrity, the fire alarm system
shall have an approved maintenance and testing program
complying with the applicable requirements of NFPA 70, National
Electrical Code, and NFPA 72, National Fire Alarm and Signaling
Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition.
Chapter 14 Inspection, Testing, and Maintenance
14.1 Application.
14.1.1 The inspection, testing, and maintenance of systems,
their initiating devices, and notification appliances shall comply
with the requirements of this chapter.

Table 14.3.1 Visual Inspection Frequencies

14.4.5* Testing Frequency. Unless otherwise permitted by
other sections of this Code, testing shall be performed in accordance
with the schedules in Table 14.4.5, or more often if
required by the authority having jurisdiction.

Table 14.4.5 Testing Frequencies

14.6.2 Maintenance, Inspection, and Testing Records.
14.6.2.1 Records shall be retained until the next test and for
1 year thereafter.
14.6.2.4* A 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 14.6.2.4:
(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
(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) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification
systems
(14) Functional test of ability of mass notification system to
silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer ' s
published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system
owner notified, problem corrected/successfully retested,
device abandoned in place)

Findings:

During a facility tour, document review, and interview with staff on 6/20/17, the FAS was observed and records were requested.

At 12:35 p.m., the facility was observed with an automatic FAS. An "Annual Fire Alarm Test and Inspection" was completed on 4/15/16. No semi-annual visual inspection, prior to, or after the current annual inspection was available for review. Upon interview, Staff 2 confirmed that the FAS is inspected and tested on an annual basis.

Based on observation and interview, the facility failed to maintain the integrity of automatic fire sprinkler system and components. This was evidenced by corrosion on a sprinkler head. This affected one of nine smoke compartments, and could result in the ineffective operation of the automatic fire sprinkler system in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.5 Extinguishment Requirements.
19.3.5.1 Buildings containing nursing homes shall be protected
throughout by an approved, supervised automatic
sprinkler system in accordance with Section 9.7, unless otherwise
permitted by 19.3.5.5.
19.3.5.4* The sprinkler system required by 19.3.5.1 or 19.3.5.3
shall be installed in accordance with 9.7.1.1(1).
19.3.5.5 In Type I and Type II construction, alternative protection
measures shall be permitted to be substituted for sprinkler
protection in specified areas where the authority having
jurisdiction has prohibited sprinklers, without causing a building
to be classified as nonsprinklered.
9.7 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.1 Automatic Sprinklers.
9.7.1.1* Each automatic sprinkler system required by another
section of this Code shall be in accordance with one of the
following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in
One- and Two-Family Dwellings and Manufactured Homes
(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in
Residential Occupancies up to and Including Four Stories in
Height
9.7.5 Maintenance and Testing. All automatic sprinkler and
standpipe systems required by this Code shall be inspected,
tested, and maintained in accordance with NFPA 25, Standard
for the Inspection, Testing, and Maintenance of Water-Based Fire Protection
Systems.
9.7.6 Sprinkler System Impairments. Sprinkler impairment
procedures shall comply with NFPA 25, Standard for the Inspection,
Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition.
4.3 Records
4.3.1* Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.

Chapter 5 Sprinkler Systems.
5.1.1 Minimum Requirements.
5.1.1.1 This chapter shall provide the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.
5.2.1 Sprinklers.
5.2.1.1 Sprinklers shall be inspected from the floor level annually.
5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).

Findings:

During a facility tour and interview with staff on 6/20/17, the automatic fire sprinkler system was observed.

At 2 p.m., the sprinkler heads located in Dietary above the dish washing machine was observed. The sprinkler head had a green colored corrosion build-up on the frame and deflector. Upon interview, Staff 5 confirmed the finding.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by an unsealed corridor wall penetration. This affected one of nine smoke compartments, and could result in the passage of smoke to other areas in the event of a fire.

Findings:

During a tour of the facility with staff on 6/20/17, the walls and ceilings were observed.

At 2:30 p.m., the walls in the Emergency Room (ER) corridor were observed. There was an approximately one-half inch diameter penetration inside a metal conduit in the east wall beside the Electrical Room door.

Based on document review and interview, the facility failed to maintain the Heating, Ventilating, and Air-Conditioning (HVAC) system. This was evidenced by failure to perform the smoke/fire damper inspection and testing. This affected nine of nine smoke compartments, and could result in the spread of smoke and/or fire to other locations of the facility due to a malfunctioning damper.

NFPA 101. Life Safety Code, 2012 Edition
19.5.2 Heating, Ventilating, and Air-Conditioning.
19.5.2.1 Heating, ventilating, and air-conditioning shall comply
with the provisions of Section 9.2 and shall be installed in
accordance with the manufacturer ' s specifications, unless otherwise
modified by 19.5.2.2.
19.5.2.2* Any heating device, other than a central heating
plant, shall be designed and installed so that combustible material
cannot be ignited by the device or its appurtenances,
and the following requirements also shall apply:
(1) If fuel-fired, such heating devices shall comply with the
following:
(a) They shall be chimney connected or vent connected.
(b) They shall take air for combustion directly from the
outside.
(c) They shall be designed and installed to provide for
complete separation of the combustion system from
the atmosphere of the occupied area.
(2) Any heating device shall have safety features to immediately
stop the flow of fuel and shut down the equipment in
case of either excessive temperature or ignition failure.
9.2 Heating, Ventilating, and Air-Conditioning.
9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and
Related Equipment. Air-conditioning, heating, ventilating
ductwork, and related equipment shall be in accordance with
NFPA 90A, Standard for the Installation of Air-Conditioning and
Ventilating Systems, or NFPA 90B, Standard for the Installation of
Warm Air Heating and Air-Conditioning Systems, as applicable, unless
such installations are approved existing installations,
which shall be permitted to be continued in service.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 edition.
5.4.8 Maintenance.
5.4.8.1 Fire dampers and ceiling dampers shall be maintained
in accordance with NFPA 80, Standard for Fire Doors and
Other Opening Protective's.
NFPA 80, Standard for Fire Doors and Other Opening Protective's, 2010 edition.
19.4.1.1
19.4* Periodic Inspection and Testing.
19.4.1 Each damper shall be tested and inspected 1 year after
installation.
19.4.1.1 The test and inspection frequency shall then be every
4 years, except in hospitals, where the frequency shall be every
6 years.

Findings:

During document review and interview with staff on 6/20/17, the HVAC damper testing/service records were requested for review.

At 1:45 p.m., the current report for service and testing of smoke/fire dampers was requested. Upon interview, Staff 2 confirmed that were no current or previous inspection and testing for the smoke/fire dampers.

Based on document review and interview, the facility failed to maintain fire drills. This was evidenced by failure to activate the fire alarm system during fire drills. This affected nine of nine smoke compartments, and could result in staff being untrained and unaware of shift-specific roles and responsibilities during an emergency.


Findings:

During document review and interview with Staff on 6/20/17, the fire drill records were reviewed.

At 11:20 a.m., the fire drill records indicated there was no alarm device activated during the first quarter P.M. shift on 3/28/17 at 7:00-7:30 p.m. Upon interview, Staff 5 confirmed the finding and indicated they were not aware of the time requirements for alarm activation.

Based on observation, the facility failed to maintain the electrical wiring and connections. This was evidenced by the use of extension cords and re-locatable power taps (RPT). This affected three of nine smoke compartments, and could potentially result in electrical shock or ignition of an electrical fire.

NFPA 101, Life Safety Code, 2012 Edition
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of section 9.1
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 Edition.
110.12 Mechanical Execution of Work. Electrical equipment
shall be installed in a neat and workmanlike manner.
Informational Note: Accepted industry practices are described
in ANSI/NECA 1-2006, Standard Practices for
Good Workmanship in Electrical Contracting, and other
ANSI-approved installation standards.
400.8 Uses Not Permitted. Unless specifically permitted in 400.7 in, flexible cords and cables shall not be used for the following:
(1)As a substitute for the fixed wiring of a structure
(2)Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3)Where run through doorways, windows, or similar openings
(4)Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B).
(5)Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6)Where installed in raceways, except as otherwise permitted in this Code
(7)Where subject to physical damage
400.10 Pull at Joints and Terminals. Flexible cords and cables shall be connected to devices and to fittings so that tension is not transmitted to joints or terminals.
Exception: Listed portable single-pole devices that are intended to accommodate such tension at their terminals shall be permitted to be used with single-conductor flexible cable.
Informational Note: Some methods of preventing pull on a cord from being transmitted to joints or terminals are knotting the cord, winding with tape, and fittings designed for the purpose.
Findings:

During a tour of the facility with Staff on 6/20/17, the electrical wiring and connections were observed.

1. At 1:50 p.m., the electrical equipment in the Business Office was observed. A RPT was used to power a portable room heater.

2. At 1:55 p.m., the electrical equipment in the Physician's Assistant Office was observed. A RPT was used to power a portable room heater.

3. At 2:10 p.m., the electrical equipment in the Employee Lounge was observed. An extension cord was plugged into a micro-wave oven and it was partially hanging and was suspended above the floor.

Based on observation, the facility failed to maintain oxygen storage. This was evidenced by one storage room door that was not secured against unauthorized entry. This affected one of nine smoke compartments, and could result in an unsafe and unauthorized use of oxygen.

NFPA 99, Health Care Facilities Code, 2012 Edition.
11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.

Findings:

During a tour of the facility with staff on 6/20/17, the oxygen storage was observed.

At 2:15 p.m., the inside portable Oxygen Storage Room was observed. The door was not equipped with a locking device to secure against unauthorized entry.