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Based on observation and staff interview, the facility failed to protect hazardous areas in accordance with the 2012 NFPA 101, Life Safety Code. Failure to protect hazardous areas could result in injury or death in the event of a fire. The deficiencies affected one (1) of seven (7) smoke compartments. The findings were:

Observation on 09/17/19 at 11:05 AM revealed a storage room containing combustible supplies set between the IT office and Biomed Office. The storage room was missing a door to one of the offices and had no door closer on the other office. Hazardous areas shall be separated from other spaces by smoke partitions and shall have self or automatic closing doors.

Interview with the facilities director at the time of the observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2012 NFPA 101 Section 19.3.2.1.2, 19.3.2.1.3

Observation on 09/17/19 at 11:45 AM revealed that the Central Supply storage room contained combustible storage and did not have a door closer. Hazardous areas shall be separated from other spaces by smoke partitions and shall have self or automatic closing doors.

Interview with the facilities director at the time of the observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2012 NFPA 101 Section 19.3.2.1.2, 19.3.2.1.3
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Based on observation and staff interview, the facility failed to provide a fire alarm system in accordance with the 2012 NFPA 101, Life Safety Code. Failure to provide a fire alarm system as required could result in injury or death in the event of a fire. The deficiency affected one (1) of seven (7) smoke compartments. The findings were:

Observation on 09/17/19 at 10:55 AM revealed that the exit to the exterior in the employee corridor did not have a manual fire alarm box located near it. A manual fire alarm box shall be provided in the natural exit access path near each required exit or within 60 inches of exit doorways.

Interview with the facilities director at the time of the observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2012 NFPA 101 Section 19.3.4.2.1, 9.6.2.3(2)
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Based on document review and staff interview, the facility failed to test the fire alarm system in accordance with the 2010 NFPA 72, National Fire Alarm and Signaling Code. Failure to test the fire alarm system as required could result in injury or death in the event of a fire. The deficiencies affected seven (7) of seven (7) smoke compartments. The findings were:

Document review on 09/18/19 at 11:00 AM revealed that the facility was not activating the fire alarm system at least once a month. Monthly activating of the fire alarm system is required.

Interview with the facilities director at the time of the observation acknowledged the deficiency, and indicated he was unaware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2010 NFPA 72 Table 14.4.5(24)

Document review on 09/18/19 at 11:00 AM revealed that the facility had conducted a load voltage test on the fire alarm batteries once in the last twelve months. A load voltage test on the fire alarm batteries must be conducted once every 6 months.

Interview with the facilities director at the time of the observation acknowledged the deficiency, and indicated they were unaware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2010 NFPA 72 Table 14.4.5(6)(3)

Document review on 09/18/19 at 11:00 AM revealed that the facility had conducted the annual testing of the alarm notification devices in the last twelve months. However, the testing documentation did not include the location of each alarm notification device.

Interview with the facilities director at the time of the observation acknowledged the deficiency, and indicated he was unaware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2010 NFPA 72 Figure 14.6.2.4 Page 11
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Based on observation and staff interview, the facility failed to install the fire sprinkler system in accordance with the 2010 NFPA 13, Standard for the Installation of Sprinkler Systems. Failure to install the fire sprinkler system could result in injury or death in the event of a fire. The deficiency affected one (1) of seven (7) smoke compartments. The findings were:

Observation on 09/17/19 at 1:50 PM revealed that the RNF X-Ray room had suspended equipment that could be moved and placed underneath a sprinkler head and obstruct the sprinkler discharge pattern. When the suspended equipment was placed under the sprinkler head the room was no longer fully covered. Sprinklers shall be located so as to minimize obstructions to discharge or additional sprinklers shall be provided to ensure adequate coverage of the area.

Interview with the facilities director at the time of the observation acknowledged the deficiency, and indicated he was aware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2010 NFPA 13 8.6.5.1.1
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Based on observation and staff interview, the facility failed to protect corridor doors in accordance with the 2012 NFPA 101, Life Safety Code. Failure to protect corridor doors could result in injury or death in the event of a fire. The deficiency affected one (1) of seven (7) smoke compartments. The findings were:

Observation on 09/17/19 at 4:00 PM revealed that the EVS locker room had a transfer grill installed on the corridor door. Transfer grilles shall not be used in corridor doors.

Interview with the facilities director at the time of the observation acknowledged the deficiency, and indicated he was unaware of the requirement.

Interview with the administrator at the time of exit acknowledged the deficiency.

Reference: 2012 NFPA 101 Section 19.3.6.4.1