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Based on observation on January 12 -13, 2016 at approximately 12:00 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

These hazardous rooms are not equipped with an approved fire suppression system (Sprinkler): Therefore the rooms are required to be one hour rated. These rooms contain combustibles and are greater than 50 sq ft in area.

1. The one hour fire rated wall separating the clean supply room and the machine room has HVAC ducts penetrating the one hour fire rated wall and the facility could not verify the the penetrations were equipped with UL rated fire dampers in order to maintain the required fire resistance rating of the wall.
2. The main supply storage room has HVAC ducts penetrating the 1 hour fire rated wall and the facility could not verify the ducts were equipped with UL rated fire dampers in order to maintain the required fire resistance rating of the wall.

Hazardous areas shall be One hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with NFPA 101, sections 8.4.1, 19.3.2.1 and/or 19.3.5.4 protects hazardous areas.

HVAC in rated walls shall meet NFPA 101, Sections 19.5.2, 9.2 & NFPA 90 A Section 3-3.1

This deficiency affected two of six smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observation on January 12 -13, 2016 at approximately 12:00 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1.The automatic sprinkler system was non-compliant, specific findings include: The sprinkler tamper supervisory signal could be silenced permanently. Supervisory signals shall not be silenced permanently except by reopening/restoration of the valve.
equired automatic sprinkler systems have valves supervised so that at least a local alarm will sound when the valves are closed. NFPA 101, 2000 ed, Section 9.7.2.1

Reference NFPA 101, Sections 18.7.6, 4.6.12, NFPA 101, 2000 ed, Section 9.7.2.1 NFPA 72

Thes deficency affect 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 observation on January 12 -13, 2016 at approximately 12:00 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. In the Kitchen, area protected by approved fire suppression (sprinkler) system, there are mixed sprinkler heads in the facility rated for Intermediate Temperature Classification, Glass Bulb Color of Green temperature rating of (200°F) and Ordinary Temperature Classification, Glass Bulb Color of Red temperature rating of (155°F) in the same space. Note: The kitchen is an air conditioned space space classified as ordinary environment.


Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. Sprinkler heads in same space/compartment shall be of same type or compatible heads. Compatibility shall be verified by Sprinkler System Design engineer of record, NICET Level III, NFPA 101 Sections 19.7.6, 4.6.12, , 9.7.5, NFPA 13, Section ,5-3.1.5.2


The deficiency affected one of six smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observation on January 12 -13, 2016 at approximately 12:00 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The portable fire extinguishers for the Heli-pad was was not readably accessible. The fire extinguishers were located in the fire extinguisher shed and at the time of the survey the shed was pad locked shut.
2. The large wheeled portable fire extinguisher for the heli-pad was not hydrostatic tested in the last six years. Last hydrostatic test was conducted in 2006.

Portable fire extinguishers are provided in all health care occupancies in accordance with NFPA 101, Sections, 9.7.4.1., 19.3.5.6, Portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10, Section 5-2 - Standard for Portable Fire Extinguishers.

This deficiency affected the Heli-Pad area.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

Based on observation on January 12 -13, 2016 at approximately 12:00 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. In patient room 156 the HVAC duct penetrating the smoke barrier wall (next to the outside wall) is not equipped with a smoke damper.
Heating, ventilating, and air conditioning comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications.
NFPA 101, Sections 19.5.2.1, 19.3.7.3 and 9.2,
NFPA 90A,4-4.4.1

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

Based on observation on January 12 -13, 2016 at approximately 12:00 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The following Heating, Ventilating, and Air Conditioning system (HVAC) was non-compliant; specific findings include
A. The HVAC system for the laundry room above door (BCH2-105) did not shut down with fire alarm activation
.
Heating, ventilating, and air conditioning comply with the provisions of NFPA 101, section 9.2 and are installed in accordance with the manufacturer's specifications. NFPA 101, Sections 19.5.2.1, 9.2 & NFPA 90A, 4-4.2

2. No access door for the smoke duct detectors for unit M1-152, and M1-147 above door (BCH1-105) was not provided for in order to clean inspect and maintain the device
.
Heating, ventilating, and air conditioning comply with the provisions of NFPA 101, section 9.2 and are installed in accordance with the manufacturer's specifications. NFPA 101, Sections 19.5.2.1, 9.2 & NFPA 90A, Section 2-3.4.1

3. Ceiling radiation dampers, required to maintain the one hour rating of the ceiling , were not provided for in the supply and return HVAC duct located in the Fire Alarm Control Panel (FACP) room.
NFPA 101, Section 8.2.3.2.4.1: Openings in fire barriers for air handling duct-work or air movement shall be protected in accordance with NFPA 101,
Sections 19.5.2.1, 9.2.1. and NFPA 90 A, Section 3-3.2


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 observation on January 12 -13, 2016 at approximately 12:00 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. At the time of the survey the facility was not able to provide a log of the relative humidity for the operating rooms since the end of December of 2015.)

Relative humidity in anesthetizing location is maintained equal to or greater than 35%. NFPA 101, section 19.3.2.3, NFPA 99 -4.3.1.2.3(n) and 5.4.1.1

Def affected one of two smoke compartments
Failure to comply with minimum standards as referenced increases the risk of death or injury due to improper humidity.

Based on observation on January 12 -13, 2016 at approximately 12:00 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The smoke damper located in the the smoke barrier wall above corridor door BCH-1-033 did not close upon activation of the fire alarm system by smoke detection system.

Penetrations of smoke barriers by ducts are protected in accordance with NFPA 101: 8.3.6. Dampers in air transfer openings shall close upon detection of smoke by an approved smoke detectors installed in accordance with NFPA 101: Sections 19.3.7.3, 8.3.5.3


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

Based on observation on January 12 -13, 2016 at approximately 12:00 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The smoke damper located in the smoke barrier wall above door (BCH2-105) did not close upon activation of the fire alarm system.

Penetrations of smoke barriers by ducts are protected in accordance with NFPA 101: 8.3.6. Dampers in air transfer openings shall close upon detection of smoke by an approved smoke detectors installed in accordance with NFPA 101: Sections 19.3.7.3 and 8.3.5.3

This deficiency affected two of six smoke compartments
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observation on January 12 -13, 2016 at approximately 12:00 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Facility at the time of the survey were not familiar on how to test the emergency generator with loss of normal power to the Life Safety Transfer switch .
2. Facility was not able to provide a Low fuel alarm when the main fuel storage tank contains less than a 3-hour operating supply for the emergency generator.

NFPA 101, Section 19.7.6, 7.9.2.3, 4.6.12, NFPA 99: 3.4.4.1, NFPA 110, Section 3-4.2

This deficiency affect the entire facility.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to loss of normal power.

Based on observation on January 12 -13, 2016 at approximately 12:00 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

These hazardous rooms are not equipped with an approved fire suppression system (Sprinkler): Therefore the rooms are required to be one hour rated. These rooms contain combustibles and are greater than 50 sq ft in area.

1. The one hour fire rated wall separating the clean supply room and the machine room has HVAC ducts penetrating the one hour fire rated wall and the facility could not verify the the penetrations were equipped with UL rated fire dampers in order to maintain the required fire resistance rating of the wall.
2. The main supply storage room has HVAC ducts penetrating the 1 hour fire rated wall and the facility could not verify the ducts were equipped with UL rated fire dampers in order to maintain the required fire resistance rating of the wall.

Hazardous areas shall be One hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with NFPA 101, sections 8.4.1, 19.3.2.1 and/or 19.3.5.4 protects hazardous areas.

HVAC in rated walls shall meet NFPA 101, Sections 19.5.2, 9.2 & NFPA 90 A Section 3-3.1

This deficiency affected two of six smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observation on January 12 -13, 2016 at approximately 12:00 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1.The automatic sprinkler system was non-compliant, specific findings include: The sprinkler tamper supervisory signal could be silenced permanently. Supervisory signals shall not be silenced permanently except by reopening/restoration of the valve.
equired automatic sprinkler systems have valves supervised so that at least a local alarm will sound when the valves are closed. NFPA 101, 2000 ed, Section 9.7.2.1

Reference NFPA 101, Sections 18.7.6, 4.6.12, NFPA 101, 2000 ed, Section 9.7.2.1 NFPA 72

Thes deficency affect 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 observation on January 12 -13, 2016 at approximately 12:00 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. In the Kitchen, area protected by approved fire suppression (sprinkler) system, there are mixed sprinkler heads in the facility rated for Intermediate Temperature Classification, Glass Bulb Color of Green temperature rating of (200°F) and Ordinary Temperature Classification, Glass Bulb Color of Red temperature rating of (155°F) in the same space. Note: The kitchen is an air conditioned space space classified as ordinary environment.


Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. Sprinkler heads in same space/compartment shall be of same type or compatible heads. Compatibility shall be verified by Sprinkler System Design engineer of record, NICET Level III, NFPA 101 Sections 19.7.6, 4.6.12, , 9.7.5, NFPA 13, Section ,5-3.1.5.2


The deficiency affected one of six smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observation on January 12 -13, 2016 at approximately 12:00 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The portable fire extinguishers for the Heli-pad was was not readably accessible. The fire extinguishers were located in the fire extinguisher shed and at the time of the survey the shed was pad locked shut.
2. The large wheeled portable fire extinguisher for the heli-pad was not hydrostatic tested in the last six years. Last hydrostatic test was conducted in 2006.

Portable fire extinguishers are provided in all health care occupancies in accordance with NFPA 101, Sections, 9.7.4.1., 19.3.5.6, Portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10, Section 5-2 - Standard for Portable Fire Extinguishers.

This deficiency affected the Heli-Pad area.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

Based on observation on January 12 -13, 2016 at approximately 12:00 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. In patient room 156 the HVAC duct penetrating the smoke barrier wall (next to the outside wall) is not equipped with a smoke damper.
Heating, ventilating, and air conditioning comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications.
NFPA 101, Sections 19.5.2.1, 19.3.7.3 and 9.2,
NFPA 90A,4-4.4.1

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

Based on observation on January 12 -13, 2016 at approximately 12:00 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The following Heating, Ventilating, and Air Conditioning system (HVAC) was non-compliant; specific findings include
A. The HVAC system for the laundry room above door (BCH2-105) did not shut down with fire alarm activation
.
Heating, ventilating, and air conditioning comply with the provisions of NFPA 101, section 9.2 and are installed in accordance with the manufacturer's specifications. NFPA 101, Sections 19.5.2.1, 9.2 & NFPA 90A, 4-4.2

2. No access door for the smoke duct detectors for unit M1-152, and M1-147 above door (BCH1-105) was not provided for in order to clean inspect and maintain the device
.
Heating, ventilating, and air conditioning comply with the provisions of NFPA 101, section 9.2 and are installed in accordance with the manufacturer's specifications. NFPA 101, Sections 19.5.2.1, 9.2 & NFPA 90A, Section 2-3.4.1

3. Ceiling radiation dampers, required to maintain the one hour rating of the ceiling , were not provided for in the supply and return HVAC duct located in the Fire Alarm Control Panel (FACP) room.
NFPA 101, Section 8.2.3.2.4.1: Openings in fire barriers for air handling duct-work or air movement shall be protected in accordance with NFPA 101,
Sections 19.5.2.1, 9.2.1. and NFPA 90 A, Section 3-3.2


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 observation on January 12 -13, 2016 at approximately 12:00 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. At the time of the survey the facility was not able to provide a log of the relative humidity for the operating rooms since the end of December of 2015.)

Relative humidity in anesthetizing location is maintained equal to or greater than 35%. NFPA 101, section 19.3.2.3, NFPA 99 -4.3.1.2.3(n) and 5.4.1.1

Def affected one of two smoke compartments
Failure to comply with minimum standards as referenced increases the risk of death or injury due to improper humidity.

Based on observation on January 12 -13, 2016 at approximately 12:00 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The smoke damper located in the the smoke barrier wall above corridor door BCH-1-033 did not close upon activation of the fire alarm system by smoke detection system.

Penetrations of smoke barriers by ducts are protected in accordance with NFPA 101: 8.3.6. Dampers in air transfer openings shall close upon detection of smoke by an approved smoke detectors installed in accordance with NFPA 101: Sections 19.3.7.3, 8.3.5.3


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

Based on observation on January 12 -13, 2016 at approximately 12:00 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The smoke damper located in the smoke barrier wall above door (BCH2-105) did not close upon activation of the fire alarm system.

Penetrations of smoke barriers by ducts are protected in accordance with NFPA 101: 8.3.6. Dampers in air transfer openings shall close upon detection of smoke by an approved smoke detectors installed in accordance with NFPA 101: Sections 19.3.7.3 and 8.3.5.3

This deficiency affected two of six smoke compartments
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observation on January 12 -13, 2016 at approximately 12:00 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Facility at the time of the survey were not familiar on how to test the emergency generator with loss of normal power to the Life Safety Transfer switch .
2. Facility was not able to provide a Low fuel alarm when the main fuel storage tank contains less than a 3-hour operating supply for the emergency generator.

NFPA 101, Section 19.7.6, 7.9.2.3, 4.6.12, NFPA 99: 3.4.4.1, NFPA 110, Section 3-4.2

This deficiency affect the entire facility.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to loss of normal power.