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The facility failed to ensure the fire resistance rating of occupancy separation walls. 19.1.3.5, 8.2.1.3

Observation determined the door through the two-hour fire resistant rated occupancy separation wall from the Hospital to the Clinic 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.

This deficiency affected one (1) of one (1) door through the two-hour fire resistant rated occupancy separation wall in the facility.

The facility failed to maintain the exit corridors to be free of obstructions.

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

Observation determined the following corridor doors opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened:

1) The corridor door to the RT Storage Room on the 5th floor.
2) The corridor door to the IT Room on the 4th floor.
3) The corridor door to the Laundry Room on the 3rd floor.
4) The corridor door to the Storage Room on the 3rd floor.
5) The corridor door to the Storage Room on the 2nd floor.

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 five (5) of numerous corridor doors in the means of egress throughout the facility.

The facility failed to ensure exits were arranged to provide a continuous path of escape.

Observation determined the access to the east stair enclosure on the fourth and fifth floor was through intervening spaces. The fourth floor must exit through the Surgical Suite and the fifth floor must exit through the PT/OT Suite to reach the east stair enclosure.

Failure to ensure access to exits does not travel through intervening spaces increases the risk of injury or death due to fire.

This deficiency affected exits on two (2) of five (5) floors in the facility.

The facility failed to ensure vertical openings are enclosed with construction having a fire-resistance rating of at least 1-hour.

Observation determined the fifth floor east stair enclosure wall between the PT/OT suite and the stairway terminated at the ceiling.

Failure to protect vertical openings increases the risk of injury or death due to fire.

This deficiency affected one (1) of five (5) stair enclosures in the facility.

In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow or closer than 36 in. from an air supply diffuser or return air opening. 19.3.4.5.1, 9.6.2.10.1.1, NFPA 72 17.7.4.1, A.17.7.4.1

The facility failed to ensure the smoke detection system was in compliance with NFPA 72, National Fire Alarm and Signaling Code.

Observation determined smoke detectors throughout the facility were installed within 36 in. of return air openings or air supply diffusers.

Failure to install the smoke detection system as required increases the risk of death or injury due to fire.

This deficiency affected numerous smoke detectors throughout the facility.

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:

1) The following locations were missing ceiling tile:
a) The Chapel Dressing Room.
b) The Housekeeping Closet next to the Cardio Rehab Room.
c) The Housekeeping Closet on the first floor near the main stairway.

2) NFPA 13 requires high-temperature-rated sprinklers within a 7-ft. radius cylinder extending 7-ft. above and 2-ft. below horizontal discharge unit heaters.

Sprinklers in the high-temperature zone shall be of the high-temperature classification, and sprinklers in the intermediate-temperature zone shall be of the intermediate-temperature classification. NFPA 13 8.3.2, 8.3.2.5(1), Table 8.3.2.5(a)(2).

Sprinklers throughout the facility located near horizontal discharge heaters were ordinary temperature rated where intermediate or high temperature rated sprinklers were required.



3) The Nurses Lounge on the 4th floor lacked sprinkler coverage in the shower area. The area was used to store combustible materials.

4) The Tub Room on the 3rd floor had two sprinklers with paint on the sprinklers.

5) The Radiation Storage Room on the 1st floor had two (2) pairs of sprinklers spaced 5-ft apart.

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 numerous sprinklers in the facility. The automatic sprinkler system serves the entire facility.

Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. 19.7.6, 4.6.12, NFPA 25, 5.1.1.2

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25.

Review of documentation determined the monthly inspections of the gauges and control valves of the automatic sprinkler system were not conducted in the past year.

This deficiency affected two (2) components of numerous inspections of the automatic sprinkler system in the past year. The automatic sprinkler system serves the entire facility.

Failure to inspect and test the automatic sprinkler system in accordance with NFPA 25 increases the risk of injury or death due to fire.

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 electrical receptacles throughout the facility were installed within 6 ft. of a sink and were 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 numerous receptacles throughout the facility.