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The facility failed to ensure the fire resistance rating of occupancy separation walls.

Fire doors shall latch upon closure. 19.1.3.4.1, 6.1.14.4.1, 8.3.3.1, NFPA 80 6.1.4.3.1

Observation determined the fire doors in the 2-hour barrier near the Lab Waiting Room failed to self-close and latch.

Failure to ensure the fire resistance rating of occupancy separation walls as required increases the risk of death or injury due to fire.

The deficiency affected one (1) of several doors located in 2-hour fire rated separation barriers in the facility.

During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open. 7.2.1.4.3.1

The facility failed to ensure exit access was readily available at all times.

Observation determined the corridor door to the Janitor Closet near the Pharmacy opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened.

Failure to maintain the means of egress to be available at all times increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous corridor doors in the means of egress throughout the facility.

Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 19.3.2.1

The facility failed to ensure hazardous areas in fully sprinklered existing health care occupancies were separated from other spaces by smoke-resisting partitions and latching doors.

Observation determined the corridor door to the Laundry Room was equipped with a kick-down hold open device. The door was being held open at the time of this survey.

Failure to ensure hazardous areas were separated from other spaces by smoke-resisting partitions increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous hazardous areas in the facility.

The facility failed to install cooking equipment in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.

A readily accessible means for manual activation shall be located between 1067 mm and 1219 mm (42 in. and 48 in.) above the floor, be accessible in the event of a fire, be located in a path of egress, and clearly identify the hazard protected. 19.3.2.5.1, 9.2.3, NFPA 96 10.5.1.

Observation determined the manual actuation device for the fire-extinguishing system serving the Kitchen exhaust hood was mounted at a height of more than forty-eight (48) inches above the floor. The manual pull was 60 inches above the floor.

Failure to inspect, maintain, and install the wet chemical extinguishing system in accordance with NFPA 96 increases the risk of injury or death due to fire.

This deficiency affected one (1) of one (1) wet chemical extinguishing system in the facility.

Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system. Sprinklers in high-temperature zones shall be of the high-temperature classification. 19.3.5.1, 9.7.1.1(1), NFPA 13 8.3.2, 8.3.2.5(1), Table 8.3.2.5(a)(2).

The facility failed to install the automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide adequate coverage for all portions of the building.

Observation determined one (1) sprinkler in the walk-in freezer lacked fluid in the sprinkler glass bulb.

Failure to install and maintain the automatic sprinkler system in accordance with NFPA 13 increases the risk of injury and death due to fire.

The deficiency affected one (1) of numerous sprinklers in the facility. The automatic sprinkler system serves the entire facility.

Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, they shall have a fire resistance rating of not less than ½ hour and they shall resist the transfer of smoke. 19.3.6.2.1, 19.3.6.2.2, 19.3.6.2.3

The facility failed to ensure corridors were separated from use areas by walls with at least ½-hour fire resistance rating and constructed to resist the transfer of smoke.

Observation determined the corridor wall near the Pharmacy Janitor Closet had 5 holes through the wall, preventing the resistance of smoke.

Failure to separate corridors from other areas increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous corridor walls in the facility.

Fire dampers shall be tested and inspected in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. All tests shall be completed in a safe manner by personnel wearing personal protective equipment. Full unobstructed access to the fire or combination fire/smoke damper shall be verified and corrected as required. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts. The damper frame shall not be penetrated by any foreign objects that would affect fire damper operations. The damper shall not be blocked from closure in any way. The fusible link shall be reinstalled after testing is complete. If the link is damaged or painted, it shall be replaced with a link of the same size, temperature, and load rating. All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. All documentation shall be maintained and made available for review by the AHJ. 19.5, NFPA 80, 19.4

The facility failed to test and inspect fire dampers as required by NFPA 80.

Documentation was not available to determine testing of fire dampers throughout the facility.

Failure to maintain fire dampers in accordance with NFPA 80 increases the risk of death or injury due to fire.

This deficiency affected all fire dampers in the facility.

The facility failed to conduct fire drills as required.

Fire drill records review determined:

1) No fire drills were conducted on the third Shift during the second quarter in the past year.

2) No fire drills were conducted on the second Shift during the third quarter of 2023.

3) No drills were conducted on the first, second, and third shifts during the fourth quarter of 2023.

Failure to conduct fire drills as required increases the risk of death or injury due to fire.

The deficiency affected five (5) of twelve (12) drills in the past year.

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.

Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 7.2.1.15.2

The facility failed to inspect and test fire rated door assemblies throughout the facility.

Review of documentation and interview with staff determined fire rated doors throughout the facility have not been inspected and tested in the past year.

Failure to inspect and test fire rated door assemblies increases the risk of injury or death due to fire.

The deficiency affected all fire rated door assemblies throughout the facility.

Ground-fault circuit-interruption for personnel shall be provided as required. The ground-fault circuit-interrupter shall be installed in a readily accessible location. All 125-volt, single-phase, 15- and 20-ampere receptacles located in areas other than kitchens where receptacles are installed within 6 ft. of the outside edge of the sink shall have ground-fault circuit-interrupter protection for personnel. NFPA 70, 210.8, 210.8(A)(7)

The facility failed to provide electrical wiring and equipment in accordance with NFPA 70, National Electrical Code.

Observation determined an electrical receptacle in the Dirty Utility Room near the O.B. was installed within 6 ft. of a sink and was not ground-fault circuit-interrupter protected.

Failure to provide electrical wiring and equipment in accordance with NFPA 70 increases the risk of injury or death due to fire.

The deficiency affected one of numerous receptacles in the facility.

The facility failed to ensure the emergency generator was in compliance with NFPA 99, Health Care Facilities Code and NFPA 110, Standard for Emergency and Standby Power Systems.

Documentation was not available indicating the emergency generator was exercised for 4 continuous hours in the past 36 months.

Failure to inspect, test and maintain the emergency generator in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.