HospitalInspections.org

Based on observation and interview, the facility failed to maintain the designed Type V (111) construction for this one story fully sprinklered building in accordance with NFPA 101 - 2012 Edition, Section 18.1.6.1. This deficient practice had the potential to affect 28 of the 68 patients and an indeterminate number of staff.

Findings include:

1. On 01/05/21 at 7:31 A.M., observation revealed the tenting was not in place over a light fixture in attic space above soiled linen room (B136), as specified in the building blueprints and necessary to maintain the required 1-hour fire-resistant-rating (FRR);

2. On 01/05/21 at 7:44 A.M., observation revealed the tenting was not in place over a light fixture in attic space above the main lobby, as specified in the building blueprints and necessary to maintain the required 1-hour FRR;

3. On 01/05/21 at 8:19 A.M., observation revealed a blue communication wire penetrated an unsealed hole in the exterior gypsum board wall above the suspended ceiling tiles over the emergency exit adjacent to resident room C214, as specified in the building blueprints and necessary to maintain the required 1-hour FRR; and

4. On 01/05/21 at 9:02 A.M., observation revealed four (4) can lights in the conference room ceiling, which were not provided with tenting in the attic space, as specified in the building blueprints and necessary to maintain the required 1-hour FRR.

Interview with the facility manager verified the findings at the time of observation.

Based on observation and interview, the facility failed to ensure protection from hazardous areas in accordance with NFPA 101 - 2012 Edition, Sections 18.3.2 and 8.3.3.1 and NFPA 80 - 2010 Edition, Sections 6.1.4, 6.3.1 and 6.4.1. This deficient practice had the potential to affect 18 of the 68 patients.

Findings include:

On 01/04/21 at 2:29 P.M., observation revealed positive latching hardware was not provided on either of the east leaves of both dual-leaf door systems separating the mechanical room (D101 on blue-print) from the exit corridor. In addition, the dual-leaf door systems were not provided with coordinating devices to ensure the inactive leaf closed before the active leaf. This room, which requires enclosure by way of a 1-hour fire-rated barrier and 3/4-hour fire-rated doors, contained a fuel-fired furnace. Interview with the facility manager verified this finding at the time of discovery.

Fire Barriers - Fire Doors and Windows.
Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code.
8.3.3.1

Swinging Doors with Builders Hardware - Operation of Doors - Self-Closing Doors.
Self-closing doors shall swing easily and freely and shall be equipped with a closing device to cause the door to close and latch each time it is opened.
6.1.4.2.1 (NFPA 80)

Swinging Doors with Builders Hardware - Operation of Doors - Automatic-Closing Doors.
The fire door shall latch upon closure.
6.1.4.3.1 (NFPA 80)

Swinging Doors with Builders Hardware - Openings - Door Frames - Clearances.
The clearances between the top and vertical edges of the door and the frame, and the meeting edges of doors swinging in pairs, shall be 1/8 in. +/- 1/16 in. (3.18 mm +/- 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18 mm) for wood doors.
6.3.1.7.1 (NFPA 80)

Swinging Doors with Builders Hardware - Assembly Components - Coordinating Device.
Where there is an astragal or projecting latch bolt that prevents the inactive door from closing and latching before the active door closes and latches, a coordinating device shall be used.
6.4.1.2.1 (NFPA 80)

Swinging Doors with Builders Hardware - Assembly Components - Closing Devices
All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.
6.4.1.4 (NFPA 80)

Based on observations and staff interview, the facility failed to ensure the sprinkler system installation was in accordance with NFPA 101 - 2012 Edition, Sections 18.3.5.1 and 9.7.1.1(1), and NFPA 13 - 2010 Edition, Section 8.5.5.2. This deficient practice had the potential to affect 18 of the 68 patients.

Findings include:

1. On 01/05/21 at 8:38 A.M., observation revealed batts of insulation had fallen from the attic space roof rafters above the D wing exit corridor near the C wing. A number of these fallen insulation batts obstructed the spray pattern of the attic space sprinklers; and

2. On 01/05/21 at 8:47 A.M., observation revealed batts of insulation had fallen from the attic space roof rafters above the D wing nurses station. A number of these fallen insulation batts obstructed the spray pattern of the attic space sprinklers.

Interview with the facility manager verified the findings at the time of observation.

Obstructions to Sprinkler Discharge - Obstructions to Sprinkler Discharge Pattern Development.
Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 8.5.5.2.
8.5.5.2.1 (NFPA 13)

Based on observation and interview, the facility failed to provide supervised smoke detection in spaces not separated from corridors with smoke tight partitions in accordance with NFPA 101 - 2012 Edition, Section 18.3.6.1. This deficient practice had the potential to affect an isolated number of the 68 patients, including those that may be present in the A-wing and C-wing patient lounges, and an indeterminate number of staff.

Findings include:

1. On 01/04/21 at 2:02 P.M., observation revealed the coat room (B102 on blue-print) off the main entrance lobby was open to the lobby/corridor; yet was not provided with a smoke detector; and

2. On 01/04/21 at 2:06 P.M., observation revealed the vending machine room (B105 on blue-print) off the main entrance lobby was open to the lobby/ corridor; yet was not provided with a smoke detector.

Interview with the facility director verified the findings at the time of discovery.

Corridor Separation.
Corridors shall be separated from all other areas by partitions complying with 18.3.6.2 through 18.3.6.5 (see also 18.2.5.4), unless otherwise permitted by one of the following:
(1) Spaces shall be permitted to be unlimited in area 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 in accordance with 18.3.4, 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 in accordance with 18.3.4, 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.
18.3.6.1

Based on observation and interview, the facility failed to ensure smoke barriers provided at least a one-hour fire-resistant-rating and restrict the movement of smoke in accordance with NFPA 101 - 2012 Edition, Section 18.3.7.3 and 8.5.2. This deficient practice had the potential to affect 25 of the 68 patients.

Findings include:

1. On 01/05/21 at 8:13 A.M., observation revealed flexible metal electrical conduit, penetrating a hole in the attic space 3-hour fire-resistant-rated (FRR) barrier adjacent to resident room C214, which was sealed only with pink expandable foam. At 8:37 A.M., observation revealed the south side of this penetration was also sealed only with pink expandable foam;

2. On 01/05/21 at 8:13 A.M., observation revealed a copper water pipe, penetrating a PVC pipe and hole in the attic space 3-hour FRR barrier adjacent to resident room C214, which was sealed only with pink expandable foam. At 8:28 A.M., observation of the south side of this penetration revealed the pink expandable foam was partially skim coated with what appeared to be fire caulk; and

3. On 01/05/21 at 8:36 A.M., observation revealed an unsealed and cut-off PVC pipe penetrating an unsealed hole in the attic space 3-hour FRR barrier adjacent to resident room C214.

Interview with the facility manager verified the findings at the time of observation.

Based on observation and interview, the facility failed to ensure electrical equipment was properly installed in accordance with NFPA 70 - 2011 Edition, Sections 110.13(A), 314.15 and 314.23. This deficient practice had the potential to affect an isolated number of the 68 patients, including those that may be present in the A-wing and C-wing patient lounges, and an indeterminate number of staff.

Findings include:

1. On 01/04/21 at 1:09 A.M., observation revealed the conduit to the kitchen disposal grinder had separated at the grinder junction leaving a gap which exposed the inside of the conduit body and the grinder junction to the wet conditions of the dish washing area of the kitchen;

2. On 01/05/21 at 7:28 A.M., observation revealed a four-inch by four-inch junction box with protruding non-terminated wires that was not provided with a cover plate in attic space above soiled linen room (B136);

3. On 01/05/21 at 7:44 A.M., observation revealed several wires protruding from the floor of the attic space above the main lobby, which were unterminated and not contained in a junction box or conduit; and

4. On 01/05/21 at 9:02 A.M., observation revealed four attic space junction boxes, associated with four (4) can lights in the conference room ceiling, which were not braced or mounted.

Interview with the facility manager verified the findings at the time of observation.

Requirements for Electrical Installations - Mounting and Cooling of Equipment.
Electrical equipment shall be firmly secured to the surface on which it is mounted. Wooden plugs driven into holes in masonry, concrete, plaster, or similar materials shall not be used.
110.13(A) (NFPA 70)

Installation - Damp or Wet Locations.
In damp or wet locations, boxes, conduit bodies, and fittings shall be placed or equipped so as to prevent moisture from entering or accumulating within the box, conduit body, or fitting. Boxes, conduit bodies, and fittings installed in wet locations shall be listed for use in wet locations.
314.15 (NFPA 70)

Outlet, Device, Pull, and Junction Boxes; Conduit Bodies; Fittings; and Handhole Enclosures - Supports.
Enclosures within the scope of this article shall be supported in accordance with one or more of the provisions in 314.23(A) through (H).
(A) Surface Mounting. An enclosure mounted on a building or other surface shall be rigidly and securely fastened in place. If the surface does not provide rigid and secure support, additional support in accordance with other provisions of this section shall be provided.
(B) Structural Mounting. An enclosure supported from a structural member of a building or from grade shall be rigidly supported either directly or by using a metal, polymeric, or wood brace.
(1) Nails and Screws. Nails and screws, where used as a fastening means, shall be attached by using brackets on the outside of the enclosure, or they shall pass through the interior within 6 mm (1.4 in.) of the back or ends of the enclosure. Screws shall not be permitted to pass through the box unless exposed threads in the box are protected using approved means to avoid abrasion of conductor insulation.
(2) Braces. Metal braces shall be protected against corrosion and formed from metal that is not less than 0.51 mm (0.020 in.) thick uncoated. Wood braces shall have a cross section not less than nominal 25 mm ~ 50 mm (1 in. ~ 2 in.). Wood braces in wet locations shall be treated for the conditions. Polymeric braces shall be identified as being suitable for the use.
(C) Mounting in Finished Surfaces. An enclosure mounted in a finished surface shall be rigidly secured thereto by clamps, anchors, or fittings identified for the application.
314.23 (NFPA 70)

Based on interview and record review, the facility failed to ensure fire drills were conducted in accordance with NFPA 101 - 2012 Edition, Section 18.7.1.6. This deficient practice had the potential to affect all 68 patients.

Findings include:

On 01/05/21 at 1:36 P.M., observation revealed:

1. First-shift fire drills were not conducted at unexpected times, specifically three of the five fire drills performed in 2020 were completed within 35 minutes of each other. Specifically, first-shift fire drills performed on 01/29/20, 05/07/20 and 07/15/20 were conducted at 10:15 A.M., 10:50 A.M. and 10:30 A.M., respectively;

2. Second-shift fire drills were not conducted at unexpected times, specifically three of the four fire drills performed in 2020 were completed within 40 minutes of each other. Specifically, second-shift fire drills performed on 03/07/20, 04/07/20 and 08/19/20 were conducted at 4:17 P.M., 3:50 P.M. and 4:30 P.M., respectively; and

3. Third-shift fire drills were not conducted at unexpected times, specifically all four fire drills performed in 2020 were completed within 30 minutes of each other. Specifically, third-shift fire drills performed on 02/12/20, 06/10/20, 09/16/20 and 12/17/20 were conducted at 5:15 A.M., 5:30 A.M., 5:00 A.M. and 5:15 A.M., respectively.

Interview with the facility manager verified the findings at the time of observation.

Based on observation and interview, the facility failed to prohibit portable space heaters in accordance with NFPA 101 - 2012 Edition, Section 18.7.8. This deficient practice had the potential to affect 10 of the 68 patients.

Findings include:

On 01/21/20 at 9:43 A.M., observation revealed a portable space heater in the social worker office, which was located in the same smoke compartment as patient rooms 108 through 115. Interview with the facility manager verified the finding at the time of observation.

Based on observation and interview, the facility failed to provide remote annunciator panels in locations readily observed by operating personnel at regular work stations in accordance with NFPA 99 - 2012 Edition, Section 6.4.1.1.17. This deficient practice had the potential to affect all 68 patients.

Findings include:

On 01/04/21 at 3:42 P.M., observation revealed annunciator panels for the two essential electric systems (EES) in operation at the facility were located in the boiler room. Interview with the facility manager confirmed the two EES annunciator panels located in the boiler room are the only EES annunciator panels in the facility and the boiler room is not a location that is readily observed by operating personnel at a regular work station. Interview with the facility manager verified the findings at the time of discovery.

Alarm Annunciator
A remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see 700.12 of NFPA 70, National Electrical Code). The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows:
(1) Individual visual signals shall indicate the following:
(a) When the emergency or auxiliary power source is operating to supply power to load
(b) When the battery charger is malfunctioning
(2) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
(a) Low lubricating oil pressure
(b) Low water temperature (below that required in 6.4.1.1.11)
(c) Excessive water temperature
(d) Low fuel when the main fuel storage tank contains less than a 4-hour operating supply
(e) Overcrank (failed to start)
(f) Overspeed
6.4.1.1.17 (NFPA 99)