HospitalInspections.org

Reference NFPA 101, 2000 Edition
19.3.6.4 Transfer Grills.
Transfer grills, regardless if they are protected by a fusible link-operated dampers, shall not be used in these walls [corridor walls] and doors.

Building #1:

Based on observation and staff interview, the facility failed to ensure transfer grills are not installed in corridor walls, which resulted in 3 transfer grill openings located between the conference room and the Administrative egress corridor. In the event of fire, transfer grill openings would allow smoke to travel from the conference room to the egress corridor, which presents the risk of potential harm to patients, staff and visitors. The findings are:

A. On 08/12/14 at 8:30 am, three (3) 6" X 24" transfer grills were observed installed in the corridor wall of the conference room. These grills terminated between the lay-in ceiling and the roof deck.

B. On 08/12/14 at 8:35 am, during interview, the Facilities Director stated he was unaware the transfer grills were open, he stated he thought they were sealed off.

C. On 08/13/14 at 10:30 am, the Administrator and the Director of Facilities acknowledged the above findings at the exit conference.

Reference NFPA 101, 2000 Edition

7.2.1.5 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for the operation from the egress side.

Reference NFPA 101, 2000 Edition
Section 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

Building #1:

Based on observation and staff interview, the facility failed to ensure the exit door located across from the house keeping office within the dietary corridor was free to open without swiping a badge across a security pad. Using a badge to exit this doors is similar to using a key or tool and could result in staff and/or residents not being able to freely exit through these doors in an emergency, which presents the risk of potential harm to patients, staff and visitors of the facility. The findings are:

A. On 08/12/14 at 2:20 pm, the exit door leading to the outside within the dietary corridor was observed to have magnetic locking hardware. In order to exit these doors after 8:30 pm, a badge carried by staff is required to be swiped across a security pad provided near the doors.

B. On 08/12/14 at 2:25 pm, during interview, the Facilities Director stated the installation of the badge swipe system was new. He stated he didn't know the installation posed a problem with exiting.

C. On 08/13/14 at 10:30 am, the Administrator and the Director of Facilities acknowledged the above findings at the exit conference.




Reference NFPA 101, 2000 Edition

7.2.1.6.1 Delayed-Egress Locks.
Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met.
(a) The doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with Section 9.7 or upon the actuation of any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6.
(b) The doors shall unlock upon loss of power controlling the lock or locking mechanism.
(c) An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only.
Exception: Where approved by the authority having jurisdiction, a delay not exceeding 30 seconds shall be permitted.
(d) * On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:

PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS


Building #1:

Based on observation and staff interview, the facility failed to ensure the delayed egress locking hardware installed on the set of exit doors located at the end of the 300 corridor, released within 15 seconds upon the application of force to the release device. In the event of emergency, these exit doors would not be available for egress, which presents a risk of potential harm to patients, staff and visitors of the facility. The findings are:

A. On 08/12/14 at 1:50 pm, the set of exit doors located at the end of the 300 corridor were observed equipped with delayed egress locking hardware. At this time, when the doors were tested to open within 15 seconds, the release device did not release to allow the doors to open.

B. On 08/12/14 at 2:00 pm, during interview, the Facilities Director stated he was unaware the delayed egress hardware was not releasing.

C. On 08/13/14 at 10:30 am, the Administrator and the Director of Facilities acknowledged the above findings at the exit conference.

Reference NFPA 101, 2000 Edition

9.6.2.9
Where a partial smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72, National Fire Alarm Code, shall be provided in all common areas and work spaces, such as corridors, lobbies, storage rooms, equipment rooms, and other tenantless spaces in those environments suitable for proper smoke detector operation. Selective smoke detection unique to other sections of this Code shall be provided as required by those sections.

Reference NFPA 72, 1999 Edition
2-3.4.5 Smooth Ceiling Spacing.
2-3.4.5.1 Spot-Type Detectors.
2-3.4.5.1.1
On smooth ceilings, spacing of 30 ft (9.1 m) shall be permitted to be used as a guide. In all cases, the manufacturer's documented instructions shall be followed. Other spacing shall be permitted to be used depending on ceiling height, different conditions, or response requirements.

Building #1:

Based on observation and staff interview, the facility failed to ensure the emergency room discharge vestibule was provided with automatic smoke detection as required by NFPA 72 (National Fire Alarm Code). Not providing automatic smoke detection within this vestibule could result in an undetected fire at this location, which would render the exit at this location as unavailable in the event of fire. In the event of fire, this failed practice presents a risk of potential harm to patients, staff and visitors of the facility. The findings are:

A. On 08/12/14 at 1:30 pm, an automatic smoke detection device was not observed within the emergency room discharge vestibule. This vestibule is enclosed from the other areas with walls and a door and is identified with signage as an exit to the outside, thus a smoke detector is required.

B. On 06/19/14 at 11:05 am during interview, the Maintenance Supervisor stated he never notice a smoke detector wasn't installed in the vestibule.

C. On 08/13/14 at 10:30 am, the Administrator and the Director of Facilities acknowledged the above findings at the exit conference.




NFPA 72 1999 Edition

2-3.5.1*
In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.

A-2-3.5.1 (Used for Guidance and informational purposes only)
Detectors should not be located in a direct airflow no closer than 3 ft (1 m) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.


Based on observation and staff interview, the facility failed to ensure heat detectors were located no closer than 3 ft. from direct airflow components such as air supply diffusers or return air openings, as required by NFPA 72 (National Fire Alarm Code). This failed practice could result in airflow preventing this heat detector from detecting heat, which presents a risk of potential harm to all patients, staff and occupants of the facility. The findings are:

A. On 08/12/14 at 1:40 pm, within registration #1, a smoke detector installed on the ceiling was observed too close to the air supply diffuser. This smoke detectors measured twelve (12) inches from the air supply diffuser.

B. On 08/12/14 at 1:45 pm, during interview, the Facilities Director stated he did not know the smoke detector was installed to close to the supply diffuser.

C. On 08/13/14 at 10:30 am, the Administrator and the Director of Facilities acknowledged the above findings at the exit conference.

Reference NFPA 13

1-5.1 Maintenance:
A sprinkler system installed under this standard shall be properly maintained for efficient service. The owner is responsible for the condition of the sprinkler system and shall use due diligence in keeping the system in good operating condition.

1-6.1 A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.

5-13.8* Exterior Roofs or Canopies.
5-13.8.1
Sprinklers shall be installed under exterior roofs or canopies exceeding 4 feet in width.
Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction.

Building #1:

Based on observation and staff interview, the facility failed to ensure the porched area, which also serves as a storage area, located outside near the laundry's storage room was protected from fire by the automatic fire sprinkler system in accordance with NFPA 13, (Standard for the Installation of Sprinkler Systems). This failed practice could result in spread of fire from this porched area into the facility, which presents a risk of potential harm to patients, staff and visitors of the facility. The findings are:

A. On 08/12/14 at 2:45 pm, observation of the facility revealed different construction types, one being Type II (000). This construction type requires the building to be fully sprinklered in all areas. The porched area near the laundry storage room was not sprinklered. Numerous laundry bins and miscellaneous storage items were being stored under the porched area, which also constitutes the requirement for a sprinklered space.

B. On 08/12/14 at 2:50 pm, during interview, the Facilities Director stated he was surprised the space was not protected by the sprinkler system.

C. On 08/13/14 at 10:30 am, the Administrator and the Director of Facilities acknowledged the above findings at the exit conference.

Reference NFPA 96, 1999 Edition

7-1.2
Cooking equipment that produces grease-laden vapors (such as, but not limited to, deep fat fryers, ranges, griddles, broilers, woks, tilting skillets, and braising pans) shall be protected by fire-extinguishing equipment.

Reference NFPA 17A, 1998 Edition

3-6.3
Movable cooking equipment shall be provided with a means to ensure that it is correctly positioned in relation to the appliance discharge nozzles during cooking operations.

Building #1:

Based on observation and staff interview, the facility failed to ensure the fuel fired range (on casters) was properly positioned in relation to fire extinguishing discharge nozzles as required by NFPA 96, (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations) and NFPA 17A (Standard for Wet Chemical Extinguishing Systems). In the event of fire underneath the range hood, the extinguishing system would not be effective in extinguishing fire, which presents a risk of potential harm to all patients, staff and visitors. The findings are:

A. On 08/12/14 at 2:30 pm, observation of the fuel fired range revealed the range was on casters and was pushed back toward the rear wall of the hood system which resulted in nozzles being positioned partially toward the front of the range and partially toward the floor. This range was not adequately protected by the range hoods fire extinguishing system.

B. On 08/12/14 at 2:35 pm, the Director of Facilities stated he was unaware the nozzles were not properly positioned to protect the range. He stated he was unsure if the range was not properly position underneath the nozzles or if the nozzles were not properly installed to protect the range.

C. On 08/13/14 at 10:30 am, the Administrator and the Director of Facilities acknowledged the above findings at the exit conference.



Reference NFPA 96, 1998 Edition
4-8.2 Rooftop Terminations.

4-8.2.1
Rooftop terminations shall be arranged with or provided with the following:
(e) A hinged upblast fan supplied with flexible weatherproof electrical cable and service hold-open retainer to permit proper inspection and cleaning that is listed for commercial cooking equipment, provided the ductwork extends a minimum of 18 in. (457.2 mm) above the roof surface and the fan discharges a minimum of 40 in. (1.02 m) above the roof surface (see 5-1.1)

5-1.1
Approved upblast fans with motors surrounded by the airstream shall be hinged, supplied with flexible weatherproof electrical cable and service hold-open retainers, listed for this use. Installation shall conform to the requirements of Section 4-8


Building #1:

Based on staff interview, the facility failed to ensure a hinge kit was installed on the upblast kitchen exhaust fan unit located on the roof as required by NFPA 96, (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations). Hinge kits are required to be installed on upblast fans to ensure proper and safe inspection and cleaning of the kitchen exhaust ventilation system. Without hinge kits, the fan and exhaust duct may not be completely accessible for inspection and cleaning, which presents a risk of fire from the buildup of grease. This failed practice presents the risk of potential harm by fire all patients, staff and visitors of the facility. The findings are:


A. On 08/12/14 at 9:15 am, during interview, when the Director of Facilities was asked if the upblast fan was provided with a hinge kit, he stated, "No not yet, but we [the facility] are in the process of the installing a hinge kit."

B. On 08/13/14 at 10:30 am, the Administrator and the Director of Facilities acknowledged the above findings at the exit conference.

Based on observation and staff interview, the facility failed to ensure means of egress (the action or right of going or coming out) corridors were maintained free of obstructions and impediments to full instant use, which resulted in a vital stats monitor charging within the 300 corridor. Items left unattended in egress corridors may result in staff or other emergency personnel being unable to safely and timely evacuate residents in case of fire or other emergency, which presents the risk of potential harm to all patients, staff and visitors of the facility. The findings are:

Building 1:

A. On 08/12/14 at 3:30 pm, a vital signs monitor was observed plugged into and charging from an electrical outlet located across from the nurses station within the 300 corridor.

B. On 08/12/14 at 3:35 pm, during interview, the Director of Facilities stated he was unaware staff was charging equipment in the corridor.

C. On 08/13/14 at 10:30 am, the Administrator and the Director of Facilities acknowledged the above findings at the exit conference.

Reference NFPA 101, 2000 Edition

7.2.4.3 Fire Barriers.

7.2.4.3.1
Fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground. (See also 8.2.3.)

8.2.3.2.4.2*
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.


Building #1:

Based on observation and staff interview, the facility failed to ensure the 2- hour rated fire barrier wall located near radiology was sealed to the roof deck with approved material to maintain the fire resistance of the fire barrier or protected by an approved device that is designed for the specific purpose. Incomplete construction, unprotected penetrations, openings and gaps in fire barrier walls would permit the movement of fire from one compartment to another, which presents the risk of potential harm to patients, staff and visitors of the facility. The findings are:

A. On 08/12/14 at 3:00 pm, observation of the 2-hour fire barrier wall located near radiology revealed the space where the drywall meets the corrugated metal roof deck above was filled with what appeared to be insulation or wool.

B. The Facilities Director and the Maintenance Supervisor was unable to provide documentation demonstrating the material used to seal the fire barrier wall was capable of maintaining the fire resistive rating of the barrier.


C. On 08/13/14 at 10:30 am, the Administrator and the Director of Facilities acknowledged the above findings at the exit conference.

Reference NFPA 101, 2000 Edition
19.3.6.4 Transfer Grills.
Transfer grills, regardless if they are protected by a fusible link-operated dampers, shall not be used in these walls [corridor walls] and doors.

Building #1:

Based on observation and staff interview, the facility failed to ensure transfer grills are not installed in corridor walls, which resulted in 3 transfer grill openings located between the conference room and the Administrative egress corridor. In the event of fire, transfer grill openings would allow smoke to travel from the conference room to the egress corridor, which presents the risk of potential harm to patients, staff and visitors. The findings are:

A. On 08/12/14 at 8:30 am, three (3) 6" X 24" transfer grills were observed installed in the corridor wall of the conference room. These grills terminated between the lay-in ceiling and the roof deck.

B. On 08/12/14 at 8:35 am, during interview, the Facilities Director stated he was unaware the transfer grills were open, he stated he thought they were sealed off.

C. On 08/13/14 at 10:30 am, the Administrator and the Director of Facilities acknowledged the above findings at the exit conference.

Reference NFPA 101, 2000 Edition

7.2.1.5 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for the operation from the egress side.

Reference NFPA 101, 2000 Edition
Section 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.

Building #1:

Based on observation and staff interview, the facility failed to ensure the exit door located across from the house keeping office within the dietary corridor was free to open without swiping a badge across a security pad. Using a badge to exit this doors is similar to using a key or tool and could result in staff and/or residents not being able to freely exit through these doors in an emergency, which presents the risk of potential harm to patients, staff and visitors of the facility. The findings are:

A. On 08/12/14 at 2:20 pm, the exit door leading to the outside within the dietary corridor was observed to have magnetic locking hardware. In order to exit these doors after 8:30 pm, a badge carried by staff is required to be swiped across a security pad provided near the doors.

B. On 08/12/14 at 2:25 pm, during interview, the Facilities Director stated the installation of the badge swipe system was new. He stated he didn't know the installation posed a problem with exiting.

C. On 08/13/14 at 10:30 am, the Administrator and the Director of Facilities acknowledged the above findings at the exit conference.




Reference NFPA 101, 2000 Edition

7.2.1.6.1 Delayed-Egress Locks.
Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met.
(a) The doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with Section 9.7 or upon the actuation of any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6.
(b) The doors shall unlock upon loss of power controlling the lock or locking mechanism.
(c) An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only.
Exception: Where approved by the authority having jurisdiction, a delay not exceeding 30 seconds shall be permitted.
(d) * On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:

PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS


Building #1:

Based on observation and staff interview, the facility failed to ensure the delayed egress locking hardware installed on the set of exit doors located at the end of the 300 corridor, released within 15 seconds upon the application of force to the release device. In the event of emergency, these exit doors would not be available for egress, which presents a risk of potential harm to patients, staff and visitors of the facility. The findings are:

A. On 08/12/14 at 1:50 pm, the set of exit doors located at the end of the 300 corridor were observed equipped with delayed egress locking hardware. At this time, when the doors were tested to open within 15 seconds, the release device did not release to allow the doors to open.

B. On 08/12/14 at 2:00 pm, during interview, the Facilities Director stated he was unaware the delayed egress hardware was not releasing.

C. On 08/13/14 at 10:30 am, the Administrator and the Director of Facilities acknowledged the above findings at the exit conference.

Reference NFPA 101, 2000 Edition

9.6.2.9
Where a partial smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72, National Fire Alarm Code, shall be provided in all common areas and work spaces, such as corridors, lobbies, storage rooms, equipment rooms, and other tenantless spaces in those environments suitable for proper smoke detector operation. Selective smoke detection unique to other sections of this Code shall be provided as required by those sections.

Reference NFPA 72, 1999 Edition
2-3.4.5 Smooth Ceiling Spacing.
2-3.4.5.1 Spot-Type Detectors.
2-3.4.5.1.1
On smooth ceilings, spacing of 30 ft (9.1 m) shall be permitted to be used as a guide. In all cases, the manufacturer's documented instructions shall be followed. Other spacing shall be permitted to be used depending on ceiling height, different conditions, or response requirements.

Building #1:

Based on observation and staff interview, the facility failed to ensure the emergency room discharge vestibule was provided with automatic smoke detection as required by NFPA 72 (National Fire Alarm Code). Not providing automatic smoke detection within this vestibule could result in an undetected fire at this location, which would render the exit at this location as unavailable in the event of fire. In the event of fire, this failed practice presents a risk of potential harm to patients, staff and visitors of the facility. The findings are:

A. On 08/12/14 at 1:30 pm, an automatic smoke detection device was not observed within the emergency room discharge vestibule. This vestibule is enclosed from the other areas with walls and a door and is identified with signage as an exit to the outside, thus a smoke detector is required.

B. On 06/19/14 at 11:05 am during interview, the Maintenance Supervisor stated he never notice a smoke detector wasn't installed in the vestibule.

C. On 08/13/14 at 10:30 am, the Administrator and the Director of Facilities acknowledged the above findings at the exit conference.




NFPA 72 1999 Edition

2-3.5.1*
In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.

A-2-3.5.1 (Used for Guidance and informational purposes only)
Detectors should not be located in a direct airflow no closer than 3 ft (1 m) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.


Based on observation and staff interview, the facility failed to ensure heat detectors were located no closer than 3 ft. from direct airflow components such as air supply diffusers or return air openings, as required by NFPA 72 (National Fire Alarm Code). This failed practice could result in airflow preventing this heat detector from detecting heat, which presents a risk of potential harm to all patients, staff and occupants of the facility. The findings are:

A. On 08/12/14 at 1:40 pm, within registration #1, a smoke detector installed on the ceiling was observed too close to the air supply diffuser. This smoke detectors measured twelve (12) inches from the air supply diffuser.

B. On 08/12/14 at 1:45 pm, during interview, the Facilities Director stated he did not know the smoke detector was installed to close to the supply diffuser.

C. On 08/13/14 at 10:30 am, the Administrator and the Director of Facilities acknowledged the above findings at the exit conference.

Reference NFPA 13

1-5.1 Maintenance:
A sprinkler system installed under this standard shall be properly maintained for efficient service. The owner is responsible for the condition of the sprinkler system and shall use due diligence in keeping the system in good operating condition.

1-6.1 A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.

5-13.8* Exterior Roofs or Canopies.
5-13.8.1
Sprinklers shall be installed under exterior roofs or canopies exceeding 4 feet in width.
Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction.

Building #1:

Based on observation and staff interview, the facility failed to ensure the porched area, which also serves as a storage area, located outside near the laundry's storage room was protected from fire by the automatic fire sprinkler system in accordance with NFPA 13, (Standard for the Installation of Sprinkler Systems). This failed practice could result in spread of fire from this porched area into the facility, which presents a risk of potential harm to patients, staff and visitors of the facility. The findings are:

A. On 08/12/14 at 2:45 pm, observation of the facility revealed different construction types, one being Type II (000). This construction type requires the building to be fully sprinklered in all areas. The porched area near the laundry storage room was not sprinklered. Numerous laundry bins and miscellaneous storage items were being stored under the porched area, which also constitutes the requirement for a sprinklered space.

B. On 08/12/14 at 2:50 pm, during interview, the Facilities Director stated he was surprised the space was not protected by the sprinkler system.

C. On 08/13/14 at 10:30 am, the Administrator and the Director of Facilities acknowledged the above findings at the exit conference.

Reference NFPA 96, 1999 Edition

7-1.2
Cooking equipment that produces grease-laden vapors (such as, but not limited to, deep fat fryers, ranges, griddles, broilers, woks, tilting skillets, and braising pans) shall be protected by fire-extinguishing equipment.

Reference NFPA 17A, 1998 Edition

3-6.3
Movable cooking equipment shall be provided with a means to ensure that it is correctly positioned in relation to the appliance discharge nozzles during cooking operations.

Building #1:

Based on observation and staff interview, the facility failed to ensure the fuel fired range (on casters) was properly positioned in relation to fire extinguishing discharge nozzles as required by NFPA 96, (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations) and NFPA 17A (Standard for Wet Chemical Extinguishing Systems). In the event of fire underneath the range hood, the extinguishing system would not be effective in extinguishing fire, which presents a risk of potential harm to all patients, staff and visitors. The findings are:

A. On 08/12/14 at 2:30 pm, observation of the fuel fired range revealed the range was on casters and was pushed back toward the rear wall of the hood system which resulted in nozzles being positioned partially toward the front of the range and partially toward the floor. This range was not adequately protected by the range hoods fire extinguishing system.

B. On 08/12/14 at 2:35 pm, the Director of Facilities stated he was unaware the nozzles were not properly positioned to protect the range. He stated he was unsure if the range was not properly position underneath the nozzles or if the nozzles were not properly installed to protect the range.

C. On 08/13/14 at 10:30 am, the Administrator and the Director of Facilities acknowledged the above findings at the exit conference.



Reference NFPA 96, 1998 Edition
4-8.2 Rooftop Terminations.

4-8.2.1
Rooftop terminations shall be arranged with or provided with the following:
(e) A hinged upblast fan supplied with flexible weatherproof electrical cable and service hold-open retainer to permit proper inspection and cleaning that is listed for commercial cooking equipment, provided the ductwork extends a minimum of 18 in. (457.2 mm) above the roof surface and the fan discharges a minimum of 40 in. (1.02 m) above the roof surface (see 5-1.1)

5-1.1
Approved upblast fans with motors surrounded by the airstream shall be hinged, supplied with flexible weatherproof electrical cable and service hold-open retainers, listed for this use. Installation shall conform to the requirements of Section 4-8


Building #1:

Based on staff interview, the facility failed to ensure a hinge kit was installed on the upblast kitchen exhaust fan unit located on the roof as required by NFPA 96, (Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations). Hinge kits are required to be installed on upblast fans to ensure proper and safe inspection and cleaning of the kitchen exhaust ventilation system. Without hinge kits, the fan and exhaust duct may not be completely accessible for inspection and cleaning, which presents a risk of fire from the buildup of grease. This failed practice presents the risk of potential harm by fire all patients, staff and visitors of the facility. The findings are:


A. On 08/12/14 at 9:15 am, during interview, when the Director of Facilities was asked if the upblast fan was provided with a hinge kit, he stated, "No not yet, but we [the facility] are in the process of the installing a hinge kit."

B. On 08/13/14 at 10:30 am, the Administrator and the Director of Facilities acknowledged the above findings at the exit conference.

Based on observation and staff interview, the facility failed to ensure means of egress (the action or right of going or coming out) corridors were maintained free of obstructions and impediments to full instant use, which resulted in a vital stats monitor charging within the 300 corridor. Items left unattended in egress corridors may result in staff or other emergency personnel being unable to safely and timely evacuate residents in case of fire or other emergency, which presents the risk of potential harm to all patients, staff and visitors of the facility. The findings are:

Building 1:

A. On 08/12/14 at 3:30 pm, a vital signs monitor was observed plugged into and charging from an electrical outlet located across from the nurses station within the 300 corridor.

B. On 08/12/14 at 3:35 pm, during interview, the Director of Facilities stated he was unaware staff was charging equipment in the corridor.

C. On 08/13/14 at 10:30 am, the Administrator and the Director of Facilities acknowledged the above findings at the exit conference.

Reference NFPA 101, 2000 Edition

7.2.4.3 Fire Barriers.

7.2.4.3.1
Fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground. (See also 8.2.3.)

8.2.3.2.4.2*
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.


Building #1:

Based on observation and staff interview, the facility failed to ensure the 2- hour rated fire barrier wall located near radiology was sealed to the roof deck with approved material to maintain the fire resistance of the fire barrier or protected by an approved device that is designed for the specific purpose. Incomplete construction, unprotected penetrations, openings and gaps in fire barrier walls would permit the movement of fire from one compartment to another, which presents the risk of potential harm to patients, staff and visitors of the facility. The findings are:

A. On 08/12/14 at 3:00 pm, observation of the 2-hour fire barrier wall located near radiology revealed the space where the drywall meets the corrugated metal roof deck above was filled with what appeared to be insulation or wool.

B. The Facilities Director and the Maintenance Supervisor was unable to provide documentation demonstrating the material used to seal the fire barrier wall was capable of maintaining the fire resistive rating of the barrier.


C. On 08/13/14 at 10:30 am, the Administrator and the Director of Facilities acknowledged the above findings at the exit conference.