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Based on observations, staff interview and/or documentation review on 5/21/2019, and moving forward, the following deficiencies were noted:

The facility inspection of floor separation was non-compliant the specific items include:

The facility has unsealed penetrations in the rated floor/ceiling assembly in the sixth floor I.T. closet. These penetrate the rated assembly with PVC piping. The facility was not able to provide a listing for the required fire stop involving the PVC piping penetrating the floor/ ceiling assembly.

Ref: 2012 NFPA 101 Sections 19.1.6.1

This deficiency affected two smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview and/or documentation review on 5/21/2019, and moving forward, the following deficiencies were noted:

The facility inspection of exit egress paths was non-compliant the specific items include:

1. The South Stairwell "B" required exit has a light fixture protruding greater than 4 inches into the egress path less than six feet eight inches above the finished floor.

2. The facility has housekeeping room doors that protrude greater than 4 inches into the egress corridor when opened at fully at 180 degrees and do not have door closing devices installed to keep the doors in the closed position after being opened at the following locations.

(a) 748
(b) 648
(c) 548
(d) 448

Ref: 2012 NFPA 101 Sections 19.2.1; 7.1.10.1; 7.1.5
Ref: 2012 NFPA 101 Sections 19.2.1; 7.1.10.1

This deficiency affected one smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview and/or documentation review on 5/21/2019, and moving forward, the following deficiencies were noted:

The facility inspection of special locking system was non-compliant the specific items include:

The special locking system at the third floor behavioral health unit did not have an additional emergency release switch at a regularly manned station serving the locked unit.

Ref: 2012 NFPA 101 Sections 19.3.4.; 9.6.1.5; 7.2.1.6

This deficiency affected one smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview and/or documentation review on 5/21/2019, and moving forward, the following deficiencies were noted:

The facility inspection and maintenance of suite separation was non-compliant the specific items include:

The corridor door BS645597 at on the third-floor elevator lobby did not latch properly when tested.

Ref: NFPA 101 Sections 19.2.5.7.1.2 (1); 19.3.6.3.5

This deficiency affected one smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview and/or documentation review on 5/21/2019, and moving forward, the following deficiencies were noted:

The facility inspection of exit directional signage was non-compliant the specific items include:

1. The exit directional signage near room 3502 did not have all the letter in the word "EXIT" as required.

2. The exit directional sign at the connector was not obvious as directional chevrons showing exiting from the space different from what is available to staff and patients.

Ref: 2012 NFPA 101 Sections 19.2.10.1; 7.10.1; 7.10.2; 7.10.5

This deficiency affected one smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview and/or documentation review on 5/21/2019, and moving forward, the following deficiencies were noted:

The facility inspection of vertical shafts was non-compliant the specific items include:

The facility has a vertical laundry chute on fourth-floor South in room 445 with one hour fire door that did not close and latch properly when tested.

Ref: 2012 NFPA 101 Sections 19.3.1.1

Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6

This deficiency affected one smoke compartment in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview and/or documentation review on 5/21/2019, and moving forward, the following deficiencies were noted:

The facility did not have proper protection of hazardous room was non-compliant the specific items include:

1. The first floor mechanical/ electrical room in the dietary department on the first floor is not covered by automatic sprinklers. The room is protected by two-hour construction. The door separating the rated protected room has louvers installed. This door rating cannot be maintained with louvers installed.

2. The facility dry storage room in the dietary department was wedged open. Doors with door closing devices installed shall have no impediment to the door closing.

This deficiency affected one smoke compartment in the facility.

Ref: 2000 NFPA 101 Section 19.3.2.1;19.3.2.1.5 (7); 8.7.1.3
Ref: 2000 NFPA 101 Section 19.3.6.3.5 (1)

Based on observations, staff interview and/or documentation review on 5/21/2019, and moving forward, the following deficiencies were noted:

The facility inspection of sprinkler coverage was non-compliant the specific items include:

The facility is utilizing speical locking systesms and is requried to be fully protected by an automatic sprinkler system and/or smoke detection system.

The third floor stairwell "West" is not protected by automatic sprinkler covverage or smoke detection as requried.

Ref: 2012 NFPA 101 Sections 19.3.5.1; 9.7.1; 9.7.5

This deficiency affected two smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview and/or documentation review on 5/21/2019, and moving forward, the following deficiencies were noted:

The facility inspection and testing of supervisory signals to the fire alarm control panel was non-compliant the specific items include:

The facility supervised tamper valve was tested in the south stairwell, during this test the supervisory alert was audible and visual at the fire alarm control panel. The audible signal was silenced and did not return as required.

The supervisory signal for the electronically supervised tamper alarm on the sprinkler control valve at the Fire Alarm Control Panel (FACP) could be silenced permanently when the valve was in the closed position in the sprinkler riser room. Supervisory signals shall not be silenced permanently except by reopening/restoration of the valve to the normal operating position.

Where supervised automatic sprinkler systems are required by another section of this code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed at a location within the protected building that is constantly attended by qualified personnel.

Ref: 2012 NFPA 101 Sections 19.3.5.1; 9.7.2.1
2012 NFPA 72 Section 14.1.1; 10.11.5.5

This deficiency affected the entire facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview and/or documentation review on 5/21/2019, and moving forward, the following deficiencies were noted:

The facility inspection of sprinkler heads was non-compliant the specific items include:

1. The facility has debris on quick response sprinkler head in the egress corridor across from the full oxygen storage room. Sprinklers shall have no signs of leakage, shall be free of corrosion, foreign materials paint, dust and physical damages and shall be installed in the correct orientation.

2. The facility has combustible items stored closer than 18 inches to the quick response sprinkler heads in the attic space.

3. The facility light fixture in the attic space is too close to the quick response sprinkler head.

Ref: 2012 NFPA 101 Sections 21.3.5.1; 9.7.5; 9.7.1.1*
2011 NFPA 25 Section 5.2.1.1; 5.2.1.1.2,
2011 NFPA 25 Section 8.6.5.2.1.1
2011 NFPA 25 Section 8.5.5.2.1

This deficiency affected two smoke zones in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview and/or documentation review on 5/21/2019, and moving forward, the following deficiencies were noted:

The facility inspection of smoke barrier wall areas separating suites was non-compliant the specific items include:

The facility has unsealed penetrations in the rated smoke barrier walls at the following locations:

1. First floor above the ceiling in the egress corridor near room T109

2. Second floor above the ceiling in the egress corridor at the EVS room T222

3. Third floor above the ceiling in the egress corridor at the elevator lobby East wall

4. Sixth floor above the ceiling in the egress corridor at the back side of the South wall near room 645 on the corridor side of the wall.

Ref: 2012 NFPA 101 Sections 19.3.7.1; 8.5.1

This deficiency affected two smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview and/or documentation review on 5/21/2019, and moving forward, the following deficiencies were noted:

The facility inspection of HVAC ductwork penetrating rated barrier walls was non-compliant the specific items include:

The facility has a flex ductwork grater than six inches in diamater in the elevator lobby on the seventh-floor near elevator number five that is not equipped with a fire damper as required.

Ref: 2012 NFPA 101 Sections 19.5.2.1; 9.2.1

This deficiency affected two smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview and/or documentation review on 5/21/2019, and moving forward, the following deficiencies were noted:

The facility inspection and maintenance of receptacles near water sources in the facility was non-compliant the specific items include:

The facility ground-fault circuit interrupters installed within six feet the medical sink area on the third floor did not work properly when tested.

Ref: 2012 NFPA 101 Sections 19.5.1
NFPA 99 Section 6.3.2.2.8.1

This deficiency affected one smoke compartment in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview and/or documentation review on 5/21/2019, and moving forward, the following deficiencies were noted:

The facility inspection of the generator annunciator was non-compliant the specific items include:

The remote generator annunciator is located at the nurse's station and its indicators shall be readily observed by operating personnel at a regular work station. The safety indications and shutdowns do not give all the indicators required, including low fuel main tank (h), and battery charger ac failure (n).

Ref: 2012 NFPA 101 Sections 19.2.9.1; 7.9.2.4
2012 NFPA 99 Sections 6.4.1.1.17

This deficiency affected the entire facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

Based on observations, staff interview and/or documentation review on 5/21/2019, and moving forward, the following deficiencies were noted:

The facility inspection of emergency lighting was non-compliant the specific items include:

The facility does not have emergency lighting in exit egress stairwell leading from the old OR department on the second floor of the building.

Ref: 2012 NFPA 101 Sections 19.2.9.1; 7.9.1.1

This deficiency affected one required egress in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, staff interview and/or documentation review on 5/21/2019, and moving forward, the following deficiencies were noted:

The facility inspection of the oxygen storage in the facility was non-compliant the specific items include:

1. The facility has "E" type oxygen cylinders in storage that are not 5 feet away from combustible materials in that space as required.

2. The facility oxygen storage did not have proper signage that denotes the separation full from empty oxygen cylinders as required.

Ref: 2012 NFPA 101 Section 19.3.2.4
2012 NFPA 99 Section, 11.3.2.3 (1) 11.6.5.2

This deficiency affected the only oxygen storage room in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.