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The facility failed to maintain the common wall fire barrier, desired by the facility, between the health care hospital occupancy and the health care nursing home occupancy. The facility also failed to maintain the required common wall fire barrier between the health care hospital occupancy and the non-health care occupancy clinic.

Observation determined:

1) Above the double doors near reception leading into the hospital, two (2) unsealed spaces (around 1 telephone cable and 1 flex conduit) penetrated through the 2-hr. fire-rated wall separating the hospital and nursing home.
2) Above the double doors near the lab leading to the clinic, four (4) unsealed spaces (around 2 flex conduit and 2 ends of conduit) penetrated through the 2-hr. fire-rated wall separating the hospital and the clinic.
3) Hospital Patient Room 1 was not separated from the nursing home by a 2-hr. fire-rated wall.
4) Patient Room 1 Toilet Room, located in the hospital, was not separated from Patient Room 1, located in the nursing home, by a 90-minute fire-rated door in the 2-hr. fire-rated wall.

Failure to maintain the common wall fire barrier as required increases the risk of death or injury due to fire.

The deficiency affected two (2) of three (3) occupancy separation barriers in the facility.

Notification signals for occupants to evacuate shall be audible, and visible signals in accordance with NFPA 72 shall be provided.

The facility failed to ensure visible notification devices of the fire alarm system were installed in accordance with 9.6.3.5 of NFPA 101.

Observation determined a visible notification device was not installed in the lab/x-ray bathroom.

Failure to ensure visible notification devices of the fire alarm system are installed correctly increases the risk of injury or death due to fire.

This deficiency affected one (1) of numerous locations that require visible notification devices in the facility. The fire alarm system serves the entire building.

Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 19.3.4.1

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. 9.6.1.3. 2010 NFPA 72, 14.1.1

The facility failed to test the fire alarm system as required.

Fire alarm system batteries shall be subjected to a load voltage test semiannually. NFPA 72, Table 14.4.5

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. A load voltage test of the fire alarm system batteries was done on 05/17/2019. Records did not indicate any other load voltage test on the fire alarm system batteries in the past 8 months, exceeding the allowable frequency for semiannual tests.

Failure to install, test and maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected one (1) of two (2) required load voltage tests of the fire alarm batteries in the past year. The fire alarm system serves the entire facility.

Health care facilities shall be protected throughout by an approved, supervised automatic fire sprinkler system. 19.3.5.3, 19.3.5.4, 9.7.1.1(1)

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.

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

NFPA 13 requires intermediate-temperature-rated sprinklers within a 7 ft. to 20 ft. radius pie-shaped cylinder extending 7 ft. above and 2 ft. below horizontal discharge heaters on the discharge side; also, a 7 ft. radius cylinder more than 7 ft. above horizontal discharge unit heaters.

Observation determined one (1) sprinkler in the hospital yard shed installed within 7 ft. of a unit heater was not high-temperature-rated, and two (2) sprinklers installed between 7 ft. and 20' of the unit heater were not intermediate-temperature-rated.

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

This deficiency affected three (3) of numerous sprinklers in the facility. The automatic sprinkler system serves the entire facility.