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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 self-closing doors.

Observation determined the door to the WIC Family Room in the Basement was not equipped with a self-closing device. The Room was more than 50 square feet and was used to store combustible materials.

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.

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, 14.4.2.2 item 5(e).

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 during the annual inspection by an outside company on 11/04/2021. Records did not indicate any other load voltage test on the fire alarm system batteries in the past year.

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.

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 one (1) smoke detector in the Cardiac Rehab Room was installed within 36 in. of an air supply diffuser.

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

This deficiency affected one (1) of numerous smoke detectors in the facility. The smoke detection 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

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

Observation determined there were numerous open ceiling tiles throughout the facility that could delay the activation of the sprinkler system.

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

The deficiency affected the complete automatic sprinkler system, which serves the entire 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 bathrooms, kitchens, rooftops, outdoors, indoor wet locations, locker rooms with associated showering facilities, garages and where receptacles are installed within 6 ft. of the outside edge of the sink shall have ground-fault circuit-interrupter protection for personnel. 19.5.1.1, 9.1.2, NFPA 70, 210.8, 210.8(B)

The facility failed to ensure electrical wiring and electrical equipment met the requirements of NFPA 70, National Electrical Code.

Observation determined:

1) One (1) electrical receptacle in the Respiratory Therapy Room within 6 ft. of a sink was not ground-fault circuit-interrupter protected.

2) One (1) electrical receptacle in the Basement Custodial Room within 6 ft. of a floor sink 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 two (2) of numerous electrical receptacles 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. 19.5.2.1, 9.2.1, NFPA 90A 5.4.8.1, NFPA 80, 19.4

The facility failed to test and inspect fire dampers in accordance with NFPA 80.

Review of records and staff interview determined the tests and inspections of fire dampers were not performed as required. On 08/31/2022, no records of tests and inspections of fire dampers were available.

Failure to test and inspect 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.

Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110. Critical care rooms (Category 1 Room) shall be served only by a Type I EES. General care rooms (Category 2 Room) shall be served by a Type I or Type II EES. A Type I EES serving a critical care room (Category 1 Room) shall be permitted to serve general care rooms (Category 2 Room) in the same facility. NFPA 99, 6.3.2.2.10, NFPA 110, 5.6.5.6, 5.6.5.6.1

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.

All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. The remote manual stop station shall be labeled.

Observation determined:

1) There was no remote stop switch for the 125 kW emergency generator located outside of the generator room.

2) There was no remote stop switch for the 300 kW emergency generator located outside of the generator enclosure.

Failure to ensure emergency generators are in compliance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

The deficiency affected two (2) of two (2) emergency generators which provides all emergency power and emergency lighting to 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.

Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted. Defective batteries shall be replaced immediately upon discovery of defects. NFPA 110 8.3.7.1, 8.3.7.2

Record review and interview with staff determined:

1) Weekly inspections of the emergency generators were not conducted during the past year.

2) Monthly testing and recording of the value of the emergency generators battery electrolyte specific gravity or battery conductance testing were not conducted during the past year. The batteries were maintenance free type batteries.

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 two (2) of two (2) emergency generators which provides all emergency power to the facility.