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Based on visual observation the facility failed to assure that fire doors within an exit passageway had hardware as approved means. When doors are to stairwells, smoke barriers, horizontal exits or hazardous areas doors are not maintained to its approved means.

Findings:

During the facility tour, between the hours of 9:00a.m. and 2:00p.m. it was observed the doors located in the purchasing area and the ER entry did not have the proper hardware installed to maintain approved means. The fire doors had a twisting motion lock installed that not approved hardware for the fire doors.

Interview with manager revealed the facility was not aware that the door did not have the proper hardware to maintain the approved means.

Based on visual observation the facility failed to assure that the building had a complete, supervised, automatic sprinkler system installed in accordance with NFPA 13. Activation of the sprinkler system shall trigger notification of the emergency to the fire alarm system within 90 seconds, which results in protection of life and property.

Findings:

During the facility tour, between the hours of 9:00a.m. and 2:00p.m. the Boiler room had an area where a spinkler was not located to protect the area over four feet.

NFPA 13:8.6.5.2 Obstructions to Sprinkler Discharge Pattern Development.
NFPA 13:8.6.5.2.1 General.
NFPA 13:8.6.5.2.1.1 Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 8.6.5.2.

NFPA 13:6.2.6.1.1 states "Listed corrosion-resistant sprinklers shall be installed in locations where chemicals, moisture, or other corrosive vapors sufficient to cause corrosion of such devices exist."
NFPA 13:8.15.7.5* Sprinklers shall be installed under exterior projections greater than 2 ft (0.6 m) wide over areas where combustibles are stored.
NFPA 13:8.1.1* The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers shall be installed throughout the premises.
(2) Sprinklers shall be located so as not to exceed the maximum protection area per sprinkler.
(3) Sprinklers shall be positioned and located so as to provide satisfactory performance with respect to activation time and distribution.
(4) Sprinklers shall be permitted to be omitted from areas specifically allowed by this standard.
(5) When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
(6) Clearance between sprinklers and ceilings exceeding the maximums specified in this standard shall be permitted, provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.
(7) Furniture, such as portable wardrobe units, cabinets, trophy cases, and similar features not intended for occupancy, does not require sprinklers to be installed in them. This type of feature shall be permitted to be attached to the finished structure.

NFPA 13:8.3.2.5* The following practices shall be observed to provide sprinklers of other than ordinary-temperature classification unless other temperatures are determined or unless high temperature sprinklers are used throughout, and temperature selection shall be in accordance with Table 8.3.2.5(a), Table 8.3.2.5(b), and Figure 8.3.2.5:
(10) Sprinklers in walk-in type coolers and freezers with automatic defrosting shall be of the intermediate-temperature
classification or higher.

Interview with the manager revealed the facility was not aware the automatic sprinkler system was not complete.

Based on visual observation, the facility failed to maintain the space between the penetrating item and the smoke barrier. The penetrating item must be properly filled with a material (intumescent) that is capable of maintaining the fire resistance rating in accordance with ASTM E-814 or UL1479 designed for wall cable, wire type penetrations of the smoke barrier. Unprotected penetrations would permit the movement of smoke / fire from one compartment to the other in the facility.
Findings:

During the facility tour December 12, 2022 between the hours of 10:00 a.m. to 2:15 p.m. the smoke barrier lacked proper fire stopping material at the head of wall on the purchasing, psych, radiology and CT smoke barrier walls.

NFPA 101:8.5.2.2 Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

NFPA 101: 8.3.5.1 Firestop Systems and Devices Required. Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through- Penetration Firestops, at a minimum positive pressure differential of 0.01 in. water column (2.5 N/m2) between the exposed and the unexposed surface of the test assembly.

The interview with the maintenance manager revealed the facility was aware that the smoke barrier had lacked the proper fire stopping material and was in the process to properly fll the penetrations as per code.

Based on record review, the facility failed to assure that a polarity, ground and retention resident / patient room electrical receptacle test had been conducted and documented. When the correct protocols are routinely completed by qualified personnel to the resident / patient electrical receptacle outlets chances of creating a unsafe electrical event or possible fire emergency are reduced or possibly eliminated.

Findings:

During the record of review between the hours of 9:15 am to 3:15 pm, revealed the patient operating room, preoperative unit and the post operative unit had non-hospital grade electrical receptacles located throughout and lacked documentation for annual testing of polarity, ground and retention testing.

NFPA 99 6.3.3.2 Receptacle Testing in Patient Care Rooms 6.3.3.2.1
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall not be less than 115 g (4oz.)
Section 3-3 Section 3-3.4.3.1 A record shall be maintained of the tests required by this chapter and associated repairs of modifications. At a minimum, this record shall contain date, the rooms or areas tested and an indication of which items have met or have failed to meet the performance requirements of the chapter.
6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.4.1.4 The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
6.3.4.1.5 After any repair or renovation to an electrical distribution system, the LIM circuit shall be tested in accordance with 6.3.3.3.2.
Interview with maintance manager revealed the facility was not aware that all documentation was not conducted regarding the inspection/testing of the resident / patient electrical receptacles.