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Reference NFPA 101 Life Safety Code, 2012 Edition (New Health Care)

18.1.3.9 Auditoriums, chapels, staff residential areas, or other occupancies provided in connection with the health care facilities shall have means of egress provided in accordance with other applicable sections of this Code.


Reference NFPA 101 Life Safety Code, 2012 Edition (New Assembly Occupancy)

12.2. Means of Egress Requirements
12.2.1 General. All means of egress shall be in accordance with Chapter 7 and this chapter.

7.2.1.4 Swing and Force to Open.
7.2.1.4.1* Swinging-Type Door Assembly Requirement. Any door assembly in a means of egress shall be of the side-hinged or pivoted-swinging type, and shall be installed to be capable of swinging from any position to the full required width of the opening in which it is installed, unless otherwise specified as follows:
(1) Door assemblies in dwelling units, as provided in Chapter 24, shall be permitted.
(2) Door assemblies in residential board and care occupancies, as provided in Chapters 32 and 33, shall be permitted.
(3) Where permitted in Chapters 11 through 43, horizontal sliding or vertical-rolling security grilles or door assemblies that are part of the required means of egress shall be permitted, provided that all of the following criteria are met:
(a) Such grilles or door assemblies shall remain secured in the fully open position during the period of occupancy by the general public.
(b) On or adjacent to the grille or door opening, there shall be a readily visible, durable sign in letters not less than 1 in. (25 mm) high on a contrasting background that reads as follows: THIS DOOR TO REMAIN OPEN WHEN THE BUILDING IS OCCUPIED.
(c) Door leaves or grilles shall not be brought to the closed position when the space is occupied.
(d) Door leaves or grilles shall be operable from within the space without the use of any special knowledge or effort.
(e) Where two or more means of egress are required, not more than half of the means of egress shall be equipped with horizontal-sliding or vertical-rolling grilles or door assemblies.


Based on observation and staff interview, the facility failed to ensure vertical-rolling security grilles that are part of the required means of egress were posted with signage to remain open when the space was occupied, and that the grilles are operable within the space without the use of any special knowledge or effort. Not posting signage and not being able to open the security grilles without special knowledge or effort is likely to result in these grilles preventing emergency egress from within the cafeteria. This deficient practice presents a risk of potential harm those patients, staff, and visitors that use the cafeteria. The findings are:

A. On 05/06/19 at 3:45 pm, observation of the two vertically-rolling security grilles located in the cafeteria revealed they were not posted with signage to remain open when the space was occupied. Further observation revealed both sets required to be opened and closed manually by use of a metal rod and a twisting motion, which requires both special knowledge and effort to open these grilles.

B. On 05/06/19 at 3:50 pm, during interview, the Manager of Facility Services stated signage would be posted. He stated he was in the process of converting both doors to open and close automatically with a push button.

Based on observation and interview, the facility failed to ensure the doors to hazardous areas in sprinkler spaces were self-closing. Not maintaining these doors to be self-closing is likely to result in the passage of smoke from these hazardous areas into adjacent spaces (i.e; corridors), which presents the risk of potential harm to all patients, staff and visitors on the lower level. The findings are:

A. On 05/09/19 at 11:15 am, during observation, the environmental services equipment storage room (room #0420) located on the lower level, didn't have a self-closing door. Further observation revealed the door closure had been removed. This door opens to a corridor.

B. On 05/09/19 at 11:27 am, during interview, the Manager of Facility Services stated he was unaware the door closure was removed.

NFPA Life Safety Code, 2012 Edition

19.3.2.5 Cooking Facilities.

19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4.
19.3.2.5.2* Where residential cooking equipment is used for food warming or limited cooking, the equipment shall not be required to be protected in accordance with 9.2.3, and the
presence of the equipment shall not require the area to be protected as a hazardous area.
19.3.2.5.3* Within a smoke compartment, where residential or commercial cooking equipment is used to prepare meals for 30 or fewer persons, one cooking facility shall be permitted
to be open to the corridor, provided that all of the following conditions are met:
(1) The portion of the health care facility served by the cooking facility is limited to 30 beds and is separated from other portions of the health care facility by a smoke barrier constructed
in accordance with 19.3.7.3, 19.3.7.6, and 19.3.7.8.
(2) The cooktop or range is equipped with a range hood of a width at least equal to the width of the cooking surface, with grease baffles or other grease-collecting and cleanout capability.
(3)*The hood systems have a minimum airflow of 500 cfm (14,000 L/min).
(4) The hood systems that are not ducted to the exterior additionally have a charcoal filter to remove smoke and odor.
(5) The cooktop or range complies with all of the following:
(a) The cooktop or range is protected with a fire suppression system listed in accordance with UL 300, Standard for Fire Testing of Fire Extinguishing Systems for Protection of Commercial Cooking Equipment, or is tested and meets all requirements of UL 300A, Extinguishing System Units for Residential Range Top Cooking Surfaces, in accordance with the applicable testing document ' s scope.
(b) A manual release of the extinguishing system is provided in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, Section 10.5.
(c) An interlock is provided to turn off all sources of fuel and electrical power to the cooktop or range when the suppression system is activated.
(6)*The use of solid fuel for cooking is prohibited.
(7)*Deep-fat frying is prohibited.
(8) Portable fire extinguishers in accordance with NFPA 96 are located in all kitchen areas.
(9)*A switch meeting all of the following is provided:
(a) A locked switch, or a switch located in a restricted location, is provided within the cooking facility that deactivates the cooktop or range.
(b) The switch is used to deactivate the cooktop or range whenever the kitchen is not under staff supervision.
(c) The switch is on a timer, not exceeding a 120-minute capacity, that automatically deactivates the cooktop or range, independent of staff action.
(10) Procedures for the use, inspection, testing, and maintenance of the cooking equipment are in accordance with Chapter 11 of NFPA 96 and the manufacturer ' s instructions and are followed.
(11)*Not less than two AC-powered photoelectric smoke alarms, interconnected in accordance with 9.6.2.10.3, equipped with a silence feature, and in accordance with NFPA 72,
National Fire Alarm and Signaling Code, are located not closer than 20 ft (6.1 m) from the cooktop or range.
(12) No smoke detector is located less than 20 ft (6.1 m) from the cooktop or range.
(13) The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
19.3.2.5.4* Within a smoke compartment, residential or commercial cooking equipment that is used to prepare meals for 30 or fewer persons shall be permitted, provided that the
cooking facility complies with all of the following conditions:
(1) The space containing the cooking equipment is not a sleeping room.
(2) The space containing the cooking equipment shall be separated from the corridor by partitions complying with 19.3.6.2 through 19.3.6.5.
(3) The requirements of 19.3.2.5.3(1) through (10) and (13) are met.
19.3.2.5.5* Where cooking facilities are protected in accordance with 9.2.3, the presence of the cooking equipment shall not cause the room or space housing the equipment to be
classified as a hazardous area with respect to the requirements of 19.3.2.1, and the room or space shall not be permitted to be open to the corridor.
11.2.5.2 The fusible links shall be destroyed when removed.


Based on observation and interview, facility failed to ensure fusible links provided for kitchen hood ventilation and suppression system were destroyed upon replacement. Not destroying fusible links upon removal could result in the reinstallation of used fusible links, leaving the suppression system relying on old/used parts, which could result in the failure of the suppression system in the event of a fire. This deficient practice presents a risk of injury to any patient, staff, or visitor of the facility.

A. On 05/07/19 at 11:05 am, observation of the manual pull station for kitchen hood and ventilation suppression system revealed old fusible links.

B. On 05/07/19 at 11:15 am during interview, the Dietary Manager stated "servicing agency leaves the links there for the fire marshal to see that they have been replaced."

NFPA 101 Life Safety Code, 2012 Edition

18.3.5.1* Buildings containing health care occupancies shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 18.3.5.5.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected,tested, and maintained in accordance with NFPA 25, Standard
for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

13.3.2.1 All valves shall be inspected weekly.
13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.
13.3.2.1.2 After any alterations or repairs, an inspection shall be made by the property owner or designated representative to ensure that the system is in service and all valves are in the
normal position and properly sealed, locked, or electrically supervised.
13.3.2.2* The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification

Based on record review and interview, the facility failed to ensure all fire sprinkler supervised control valves were visually inspected on a monthly basis. Not inspecting sprinkler control valves on a monthly basis as required by NFPA 25 could result in the failure of the sprinkler system to function properly in the event of a fire. This deficient practice presents a risk of injury by fire to all patients, staff and visitors of the facility. The findings are:

A. On 05/06/19 during record review, no documentation was provided to indicate sprinkler system control valves were visually inspected on a monthly basis.

B. On 05/06/19 at 10:00 am, during interview, Manager of Facilities Services indicated no monthly control valve inspections have been conducted.



NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based

15.5* Preplanned Impairment Programs.
15.5.1 All preplanned impairments shall be authorized by the impairment coordinator.
15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b)*An approved fire watch
(c)*Establishment of a temporary water supply
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.
15.6 Emergency Impairments.
15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.
15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.
15.6.3 The coordinator shall implement the steps outlined in Section 15.5.
15.7 Restoring Systems to Service. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have
been implemented:
(1) Any necessary inspections and tests have been conducted to verify that affected systems are operational. The appropriate chapter of this standard shall be consulted for guidance
on the type of inspection and test required.
(2) Supervisors have been advised that protection is restored.
(3) The fire department has been advised that protection is restored.
(4) The property owner or designated representative, insurance carrier, alarm company, and other authorities having jurisdiction have been advised that protection is restored.
(5) The impairment tag has been removed. Annex A Explanatory Material Annex A is not a part of the requirements of this NFPA document but is included for informational purposes only. This annex contains explanatory material, numbered to correspond with the applicable text paragraphs.


Based on record review and interview, the facility failed to ensure all areas of impairment program were placed into facilities standard operating procedures. Not having all portions of impairment program addressed could result in the failure of procedures when systems are out of service. This deficient practice presents a risk of injury to all patients, staff and visitors of the facility. The findings are:

A. On 05/06/19, during record review, no evidence was provided to indicate all portions of impairment programs was in place for facility procedures.

B. On 05/06/19, during interview, Manager or Facilities Services stated "not all portions of impairment program have been placed into facility procedures."

NFPA 101 Life Safety Code, 2012 Edition

18.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1-hour fire resistance rating, unless otherwise permitted by one of the following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply.
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1) (c).
(b)Not less than two separate smoke compartments shall be provided on each floor.
(2)* Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems.

8.3.4 Opening Protective's.
8.3.4.1 Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other.
8.3.4.2* The fire protection rating for opening protective's in fire barriers, fire-rated smoke barriers, and fire-rated smoke partitions shall be in accordance with Table 8.3.4.2, except as otherwise permitted in 8.3.4.3 or 8.3.4.4.

Based on observation and staff interview, the facility failed to ensure smoke barriers were constructed and properly protected from penetrations in accordance with NFPA 101, section 8.3. Incomplete construction, unprotected penetrations, openings and gaps in smoke barriers walls would permit the movement of smoke form one smoke compartment to another in the event of a fire. This deficient practice could result in the to harm patients, staff and visitors within the facility. The findings are:

A. On 05/07/19 at 9:00 am and 11:30 am, during smoke barrier inspections with Maintenance Staff #1, the surveyor observed the following:
1. At 9:15 am, inspection of the smoke barrier wall located in the Pre/Post Operations Waiting Area entrance (above fire doors) revealed a 1 and 1/2 inch diameter sleeve not properly sealed.

2. At 9:40 am, inspection of the smoke barrier wall at room 2435 (EVS) revealed an unsealed 1-inch diameter sleeve.

3. At 1:20 pm, inspection of smoke barrier walls in operating rooms suite revealed unsealed penetrations in the following locations:

(a) Near room 1206 and Operating Room #6, above ceiling, three 1-inch penetrations
(b) Between Operating Rooms #7 & #8, above ceiling, three 1-inch sleeve penetrations
(c) North wall at Operating Room #5, four 1-inch sleeve penetrations

B. On 05/08/19, at 10:00 am, during interview, Manager of Facilities Services stated, he was unaware of these penetrations in smoke barriers/1 plus hour rated walls.

NFPA 101, Life Safety Code, 2012 Edition

18.5.1 Utilities shall comply with the provisions of Section 9.1

9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

Based on observation and interview, the facility failed to ensure all electrical wiring through the facility was installed/protected as per NFPA 70, National Electrical Code, 2011 Edition. Not having all electrical wiring properly protected could result in an above ceiling fire/electrocution. This deficient practice presents a risk of injury to patients, staff, and visitors of the facility. The findings are:

A. On 05/07/19 during above ceiling inspections conducted from 8:30 am thru 2:30 pm, the surveyor identified the following electrical hazards:

1. At Room #224, above ceiling at fire doors, one (1) open junction box with exposed electrical wiring.
2. At Room #2435 (EVS), above ceiling, one (1) open junction box with exposed electrical wiring.
3. At Pre/Post Operations waiting area, above ceiling at fire doors, one (1) open junction box with exposed electrical wiring.

B. On 05/08/19, during interview, Manager of Facilities Services acknowledged the findings.

Based on observation, record review and staff interview, the facility failed to ensure all major entrances to the facility were posted with signage prohibiting smoking throughout the campus. This failed practice is likely to result in patients, staff and visitors smoking in areas away from the building (i.e. vehicles, grounds, etc.), which presents a risk of potential harm by fire to all patients, staff and visitors of the facility. The findings are:

A. On 05/06/19 at 2:00 pm, record review of the facility's smoking and tobacco policy indicated the facility and the campus are smoke/tobacco-free.

B. On 05/07/19 at 3:00 pm, observation of the 1st floor entrance revealed a "no smoking" sign at the door. However, it was unclear if the sign was for the entrance, the building or the area outside the door.

C. On 05/07/19 at 3:05 pm, during interview, the Manager of Facility Services stated smoking is prohibited on the campus. He stated the proper "no smoking" signage, like the sign provided at the lower level entrance doors, will be posted so that it provides detailed language that smoking and tobacco use is prohibited throughout the campus.