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Based upon observation, a review of records and staff interview, the facility fails to assure that a building undergoing, repair, renovation, modification, or reconstructions complies with the requirements of Chapter 18 of NFPA 101 2012. The deficient practice increases the risk of fire or smoke spreading to other areas of the building, affecting all patients, visitors and staff in 1 of 11 smoke zones. The facility has a capacity of 47 and a census of 21 at the time of the survey.

Findings include:

During the routine annual inspection on October 2nd at approximately 2:30 pm it is observed:

1. The room marked as X-ray 4 has undergone construction. No one-hour separation has been constructed between the construction area and the areas occupied by patients, staff, and visitors. The entire Imagining Center smoke compartment is open to the construction area via the path from x-ray 4 to the tech area that serves all the other imaging rooms. The door to x-ray 4 from the corridor is a 20 min door and the walls above the ceiling grid are not carried to the roof deck on two of the 4our sides.

The facility was placed into immediate jeopardy status at 3:40 PM and placed into fire watch.

This immediate jeopardy was abated at 4:00 pm when the facility began fire watch operations.
NFPA Standard: Buildings shall be permitted to be occupied during construction, repair, alterations, or additions only when required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the AHJ are in place. 2012 NFPA 101, 4.6.10.1

NFPA Standard: Protection shall be provided to separate an occupied portion of the structure from the area undergoing alteration, construction, or demolition operations when such operations are considered as having a higher level of hazard than the occupied portion of the building. Walls shall have at least a 1-hour fire resistance rating and openings shall have at least a 45 minute fire protection rating. Non-rated walls and openings shall be permitted when an approved automatic sprinkler system is installed. 2012 NFPA 241, 8.6.2

Building Rehabilitation
CFR(s): NFPA 101

Building Rehabilitation
Repair, Renovation, Modification, or Reconstruction
Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following:
* Requirements of Chapter 18 and 19
* Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6
18.1.1.4.3, 19.1.1.4.3, 43.1.2.1
Change of Use or Change of Occupancy
Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2
18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7)
Additions
Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2 hour fire resistance rating constructed of materials as required for the addition.
Communicating openings occur only in corridors and are protected by approved self closing fire doors with at least a 1 1/2 hour fire resistance rating. Additions comply with the requirements of Section 43.8.
18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8)

Based on observation, record review and staff interview, the facility failed to ensure that smoke detectors are not placed in locations where airflow prevents the operation of the detectors in accordance with NFPA 72, and that smoke detection is not covered in a way to prevent the detector from activation as intended. This deficient practice may delay operation of the smoke detectors, delaying response to a fire situation, affecting all patients, staff and visitors in one of eleven smoke zones. The facility has a capacity of 47 and census of 21 at the time of the survey.

Findings include:

During the routine annual inspection on October 2nd at approximately 2:30 pm the following is observed:

1. The smoke detector was installed on a drop ceiling; the drop ceiling was removed, and the smoke detector was not moved to the new ceiling height.

2. The smoke detector was covered with a plastic bag.


Staff B and C were present at the time of these observations and acknowledged the findings.

The Immediate Jeopardy was abated at 4:00 pm on October 2nd with the initiation of a fire watch.

Review of the following NFPA Standard revealed: 9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101, 9.6.1.3

Review of the following NFPA Standard revealed: Specific Location Requirements. The installation of smoke alarms and smoke detectors shall comply with the following requirements:

(1) Smoke alarms and smoke detectors shall not be located where ambient conditions, including humidity and temperature, are outside the limits specified by the manufacturer's published instructions.
(2) Smoke alarms and smoke detectors shall not be located within unfinished attics or garages or in other spaces where temperatures can fall below 40ºF (4ºC) or exceed 100ºF (38ºC).
(3)Where the mounting surface could become considerably warmer or cooler than the room, such as a poorly insulated ceiling below an unfinished attic or an exterior wall, smoke alarms and smoke detectors shall be mounted on an inside wall.
(4) Smoke alarms and smoke detectors shall not be installed within an area of exclusion determined by a 10 ft. (3.0 m) radial distance along a horizontal flow path from a stationary or fixed cooking appliance, unless listed for installation in close proximity to cooking appliances. Smoke alarms and smoke detectors installed between
10 ft. (3.0 m) and 20 ft. (6.1 m) along a horizontal flow path from a stationary or fixed cooking appliance shall be equipped with an alarm-silencing means or use photoelectric detection.

Exception: Smoke alarms or smoke detectors that use photoelectric detection shall be permitted for installation at a radial distance greater than 6 ft (1.8 m) from any stationary or fixed cooking appliance when the following conditions are met:
(a) The kitchen or cooking area and adjacent spaces have no clear interior partitions or headers and
(b) The 10 ft. (3.0 m) area of exclusion would prohibit the placement of a smoke alarm or smoke detector required by other sections of this code.

(5) Smoke alarms and smoke detectors shall not be installed within a 36 in. (910 mm) horizontal path from a door to a bathroom containing a shower or tub.
(6) Smoke alarms and smoke detectors shall not be installed within a 36 in. (910 mm) horizontal path from the supply registers of a forced air heating or cooling system and shall be installed outside of the direct airflow from those registers.
(7) Smoke alarms and smoke detectors shall not be installed within a 36 in. (910 mm) horizontal path from the tip of the blade of a ceiling-suspended (paddle) fan.
(8) Where stairs lead to other occupied levels, a smoke alarm or smoke detector shall be located so that smoke rising in the stairway cannot be prevented from reaching the smoke alarm or smoke detector by an intervening door or obstruction.
(9) For stairways leading up from a basement, smoke alarms or smoke detectors shall be located on the basement ceiling near the entry to the stairs.
(10) For tray-shaped ceilings (coffered ceilings), smoke alarms and smoke detectors shall be installed on the highest portion of the ceiling or on the sloped portion of the ceiling within 12 in. (300 mm) vertically down from the highest point.
(11) Smoke alarms and detectors installed in rooms with joists or beams shall comply with the requirements of 17.7.3.2.4.
(12) Heat alarms and detectors installed in rooms with joists or beams shall comply with the requirements of 17.6.3.
2010 NFPA 72, 29.8.3.4

Based upon observation, a review of records and staff interview, the facility fails to assure that a building undergoing, repair, renovation, modification, or reconstructions complies with the requirements of Chapter 18 and 19. The deficient practice increases the risk of fire or smoke spreading to other areas of the building, affecting all patients, visitors and staff in this smoke zone. The facility has a capacity of 47 with a census of 21 at the time of the survey.



During the routine hospital survey at approximately 2:30 pm on October 2nd, 2018 it is observed:

1. The facility has taken two pendant sprinklers and turned them upright, so the flow pattern is no longer functioning as they were designed.

2. The ceiling grid was removed allowing heat to bypass the sprinkler head.

Staff B and C were present and acknowledged the findings.

The Immediate Jeopardy was abated at 4:00 pm on October 2nd with the initiation of a fire watch.


Review of the following NFPA Standard revealed:
NFPA 101 Building Rehabilitation
Building Rehabilitation
Repair, Renovation, Modification, or Reconstruction
Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following:
* Requirements of Chapter 18 and 19
* Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6
18.1.1.4.3, 19.1.1.4.3, 43.1.2.1
Change of Use or Change of Occupancy
Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2
18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7)

Additions
Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2 hour fire resistance rating constructed of materials as required for the addition.
Communicating openings occur only in corridors and are protected by approved self closing fire doors with at least a 1 1/2 hour fire resistance rating. Additions comply with the requirements of Section 43.8.
18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8)