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Based on observations, record review, and interview the facility failed to maintain fire rated construction and to fully identify Hazardous Area locations which required a 1-hour rated construction per NFPA 101, 2012 edition, 19.3.2.1 and 19.3.5.9.

Fire rated construction for hazardous rooms/areas, was not fully identified nor maintained in a manner that could prevent the propagation of fire and smoke.

This deficient practice could result in failure to contain toxic products of combustion to all smoke compartments, thus placing the patients,
staff, and visitors of multiple smoke compartments in jeopardy in the event of a fire.

The surveyor observed, while accompanied by the Life Safety Officer and the Chief Nursing Officer on 07/01/2025 from 12:45 PM to 1:45 PM the following:

The electrical room, which is constructed as 2-hour rated construction, unsealed penetrations (openings). Additionally, there were multiple metal conduit sleeves that were not sealed at the end/tip.

In an interview at the time of each finding, Life Safety Officer and the Chief Nursing Officer were informed of the deficiencies, and they were able was able to observe the deficiencies.

Further interview revealed there were no other fire rated rooms; however, upon further interview during the exit interview at approximately 2:45 PM on 07/01/2025 with the Life Safety Officer and the Chief Nursing Officer, it was revealed that there was a set of architectural as-built drawings.

Record review of architectural as-built drawings showed additional 1-hour rated rooms (soiled rooms). The Life Safety Officer and the Chief Nursing Officer were informed that the information on the as-built architectural drawings depicting rated construction should be readily available and accessible to ensure proper maintenance of all rated construction.


Reference(s):
NFPA 101, 2012 edition
8.3 Fire Barriers.
8.3.1 General.
8.3.1.1 Fire barriers used to provide enclosure, subdivision, or protection under this Code shall be classified in accordance
with one of the following fire resistance ratings:
(1) 3-hour fire resistance rating
(2) 2-hour fire resistance rating
(3) 1-hour fire resistance rating
(4)*1?2-hour fire resistance rating

8.3.1.2* Fire barriers shall comply with one of the following:
(1) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
(2) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, and from the floor to the bottom of the interstitial space, provided that the construction assembly forming the bottom of the interstitial space has a fire resistance rating not less than
that of the fire barrier.
8.3.1.3 Walls used as fire barriers shall comply with Chapter 7 of NFPA 221, Standard for High Challenge Fire Walls, Fire Walls, and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.
8.3.2 Walls.
8.3.2.1 The fire-resistive materials, assemblies, and systems used shall be limited to those permitted in this Code and this chapter.


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Based on record review and interview, the facility failed to ensure a Smoke Detector Sensitivity test was completed every other year according to NFPA 72, 2012 edition, 14.4.5.3.2.

The facility did not conduct a Smoke Detector Sensitivity test ever two years.

This deficient practice could expose patients, staff and visitors to the harmful effects of smoke and fire resulting from potential delayed notification due to an improperly maintained Smoke Detection System.

Findings Included:

A record review of the facility's life safety code documents revealed there was not documentation of a Smoke Detector Sensitivity test.


Reference(s):

NFPA 101 Life Safety Code 2012 Edition
Chapter 19 Existing Health Care Occupancies
19.3 Protection.
19.3.4 Detection, Alarm, and Communications Systems.
19.3.4.1 General Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6

NFPA 101
Chapter 9 Building Service and Fire Protection Equipment
9.6 Fire Detection, Alarm, and Communications Systems.
9.6.1 General.
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 14 Inspection, Testing, and Maintenance
14.1.1 The inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter.
14.4 Testing.
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.
14.4.5 Table- Refer to 14.4.5.3.2
14.4.5.3.2 Smoke sensitivity shall be checked every alternate year unless otherwise permitted by compliance with 14.4.5.3.3.

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Based on observations and interview the facility failed to maintain smoke barrier walls to resist the passage of smoke as required by NFPA 101, Life Safety Code, 19.3.7 and 8.5.

The smoke barrier wall, which devides the hospital into two smoke compartments, had unsealed penetrations.

This deficient practice could result in failure to contain toxic products of combustion to all smoke compartments, thus placing the patients, staff, and visitors of multiple smoke compartments in jeopardy in the event of a fire.

The surveyor observed, while accompanied by the Life Safety Officer and the Chief Nursing Officer on 07/01/2025 from 12:45 PM to 1:45 PM the following:

The smoke barrier wall by Lab had unsealed penetrations (openings). Additionally, there were multiple metal conduit sleeves that were not sealed at the end/tip. There were also multiple 1-inch diameter holes that were not firestopped (sealed).

In an interview at the time of each finding, Life Safety Officer and the Chief Nursing Officer were informed of the deficiencies, and they were able was able to observe the deficiencies.

In an exit interview at approximately 2:45 PM on 07/01/2025, these deficiencies were discussed with the Life Safety Officer and the
Chief Nursing Officer.


Reference(s):
NFPA 101, 2012 edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).
(b) Not less than two separate smoke compartments shall be provided on each floor.
(2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

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Based on record review and interview, the facility failed to provide a documented categorical risk assessment, in accordance with NFPA 99, 2012 edition, Chapter 4.

This failure could compromise the hospital's building systems and could adversely affect the safety of the patients in the event such systems failed.

Findings included:

During interviews and record review on 07/01/25 from 12:45 PM to 1:45 PM, the facility's records did not include a documented categorial risk assessment based on the facility's systems (essential electrical system, information technology and communications, plumbing, and mechanical) and their possible failure and potential effect on the delivery of healthcare services for a hospital. The Chief Nursing Officer and the Life Safety Officer both confirmed the observations when the surveyor discussed the finding.

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Based on observations and interview, the facility failed to maintain the area around electrical equipment in the electrical room in accordance with NFPA 70, 2011 edition, Article 110.26.

A patient bed was stored in the electrical room which blocked access to electrical panel boards.

This deficient practice could result in a delayed response/access to electrical equipment in the event of an electrical emergency, and/or a greater fire load by storing items in the electrical room.

The surveyor observed, while accompanied by the Life Safety Officer and the Chief Nursing Officer on 07/01/2025 from 12:45 AM to 1:45 PM the following:

A patient bed was stored in the electrical room. The bed blocked access to electrical panel boards.

In an interview at the time of the observation, the Life Safety Officer and the Chief Nursing Officer both affirmed a patient bed was stored in the electrical room.


Reference(s):
NFPA 70, 2011 edition
110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.

110.26(B) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

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