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Based on observation, not all penetrations between floors were sealed limiting the transfer of smoke from one smoke compartment to another per NFPA 101, 2000 Edition, Section 18.3.1.1 and 8.2.5.1. This deficiency affects 1 of 7 main floor and 1 of 3 second floor smoke compartments.

Findings include:

1. During an observation on 8/18/16 at 8:49 a.m., penthouse 3 was inspected. The communications room had two 4-inch conduits going through the floor which were not sealed.¹ ²

¹ NFPA 101, 2000 Edition, Section 18.3.1.1; Any vertical opening shall be enclosed or protected in accordance with 8.2.5.
Exception No. 1: Unprotected vertical openings in accordance with 8.2.5.8 shall be permitted.
Exception No. 2: Exception No. 1 to 8.2.5.6(1) shall not apply to patient sleeping and treatment rooms.
Exception No. 3: Multilevel patient sleeping areas in psychiatric facilities shall be permitted without enclosure protection between levels, provided that all the following conditions are met:
(a) The entire normally occupied area, including all communicating floor levels, is sufficiently open and unobstructed so that a fire or other dangerous condition in any part shall be obvious to the occupants or supervisory personnel in the area.
(b) Egress capacity is sufficient to provide simultaneously for all the occupants of all communicating levels and areas, with all communicating levels in the same fire area being considered as a single floor area for purposes of determination of required egress capacity.
(c) The height between the highest and lowest finished floor levels shall not exceed 13 ft (4 m); the number of levels shall not be restricted.
Exception No. 4: Unprotected openings in accordance with 8.2.5.5 shall not be permitted.

² NFPA 101, 2000 Edition, Section 8.2.5.1; Every floor that separates stories in a building shall be constructed as a smoke barrier to provide a basic degree of compartmentation. (See 3.3.182 for definition of Smoke Barrier.)
Exception: This requirement shall not apply where otherwise specified by 8.2.5.5, 8.2.5.6, or Chapters 11 through 42.

Based on observation, the facility failed maintain exit signage showing the direction of travel where it may not be readily apparent per NFPA 101, 2000 Edition, Section 7.10.2. This deficiency affects the main floor and second floor egress.

Findings include:

1. During an observation on 8/18/16 at 11:02 a.m., the exit signage was inspected. There was a sign in a corridor without the chevron indicating the direction of exit.¹

¹ NFPA 101, 2000 Edition, Section 7.10.2* Directional Signs; A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Based on observation, the facility failed to maintain the one hour rating of a smoke barrier in accordance with NFPA 101, 2000 Edition, Section 18.3.7.3. This deficiency affects 1 of 7 smoke compartments.

Findings include:

1. During an observation on 8/18/16 at 9:47 a.m., the OB mall hall door smoke barrier wall was inspected. There were two 1.5 inch conduits open through the barrier.¹

¹ NFPA 101, 2000 Edition, Section 18.3.7.3; Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2*: Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems.

Based on observation, the facility failed to properly protect a hazardous area with 1-hour resistant rated walls and a self-closing rated door in accordance with NFPA 101, 2000 Edition, Sections 38.3.2.1, 8.4.1.1, and 8.4.1.3. This deficiency affects the second floor of the building.

Findings include:

1. During an observation on 8/18/16 at 11:09 a.m., the upstairs room in the clinic was inspected. It was found to be an unfinished room with windows, wood construction, and being used as general storage for medical files and other items. The door to the room was a 20-minute rated door and did not have a self-closer.¹ ² ³

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 38.3.2.1*; Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.

² NFPA 101 Life Safety Code, 2000 Edition, Section 8.4.1.1*; Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

³ NFPA 101 Life Safety Code, 2000 Edition, Section 8.4.1.3; Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

Based on observation and interview, the facility failed to protect a stairway enclosure per NFPA 101, 2000 Edition, Section 38.3.1.1, 7.2.2.5.1 and 8.2.5.4. This deficiency affects both floors of the facility.

Findings include:

1. During an observation on 8/18/16 at 11:07 a.m., the stairway to the second floor was inspected. It was not enclosed with rated doors.¹ ² ³

In an interview on 8/18/16 at 11:07 a.m., staff member A stated the walls were probably not 1 hour rated walls.

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 38.3.1.1; Any vertical opening shall be enclosed or protected in accordance with 8.2.5.
Exception No. 1: Unenclosed vertical openings in accordance with 8.2.5.8 shall be permitted.
Exception No. 2: Exit access stairs shall be permitted to be unenclosed in two-story single-tenant spaces that are provided with a single exit in accordance with Exception No. 4 to 38.2.4.2.

² NFPA 101 Life Safety Code, 2000 Edition, Section 7.2.2.5.1 Enclosures.; All inside stairs serving as an exit or exit component shall be enclosed in accordance with 7.1.3.2. All other inside stairs shall be protected in accordance with 8.2.5.
Exception: In existing buildings, where a two-story exit enclosure connects the story of exit discharge with an adjacent story, the exit shall be permitted to be enclosed only on the story of exit discharge, provided that not less than 50 percent of the number and capacity of exits on the story of exit discharge are independent of such enclosures.

³ NFPA 101 Life Safety Code, 2000 Edition, Section 8.2.5.4*; The fire resistance rating for the enclosure of floor openings shall be not less than as follows (see 7.1.3.2.1 for enclosure of exits):
(1) Enclosures connecting four stories or more in new construction - 2-hour fire barriers
(2) Other enclosures in new construction - 1-hour fire barriers
(3) Existing enclosures in existing buildings - 1/2-hour fire barriers
(4) As specified in Chapter 26 for lodging and rooming houses, in Chapter 28 for new hotels, and in Chapter 30 for new apartment buildings

Based on observation, the facility failed to ensure all exits from the facility terminate at a public way per NFPA 101, 2000 Edition, Section 7.7.1. This deficiency affects two rear exits of the building.

Findings include:

1. During an observation on 8/18/16 at 3:05 p.m., the two rear exits of the building were inspected. Both exits terminated on a concrete pad surrounded by large cobble and boulders interspersed with bushes. There was no hard packed route to the the public way from the two exits remote from the from exits.¹

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 7.7.1; Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.
Exception No. 1: This requirement shall not apply to interior exit discharge as otherwise provided in 7.7.2.
Exception No. 2: This requirement shall not apply to rooftop exit discharge as otherwise provided in 7.7.6.
Exception No. 3: Means of egress shall be permitted to terminate in an exterior area of refuge as provided in Chapters 22 and 23.

Based on observation and interview, the facility failed to ensure an emergency stop button for the generator in accordance with NFPA 110, 1999 Edition, Section 3-5.5.6. This deficiency could effect 7 of 7 smoke compartments.

Findings include:

1. During an observation on 8/17/16 at 11:06 a.m., the generator was inspected. The generator providing emergency power did not have a remote manual stop outside of the room housing the prime mover or elsewhere on the premises.¹

In an interview on 6/21/16 at 8:20 a.m., staff member A stated, the only emergency stop on the generator was the one directly on it.

¹ NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition, Section 3-5.5.6*; All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

Based on record review and interview, the facility failed to conduct load voltage tests on the batteries of the fire alarm control panel (FACP) semiannually as required per NFPA 72, 1999 Edition, Table 7-3.2. The deficiency affects 1 of 1 smoke compartment.

Findings include:

1. Review of the FACP test records reflected there was no documentation of the load voltage testing being completed.¹

During an interview on 8/15/16, at 1:11 p.m., staff member A stated load voltage testing had not been done in the clinics.

¹ NFPA 72, 1999 Edition, Table 7.3.2 (6)(d)(3), requires sealed lead-acid type batteries to have a "Load Voltage Test" upon initial installation and then semiannually thereafter.

Based on observation, the facility failed to maintain the automatic sprinkler system per NFPA 13, 1999 Edition, Section 5-15.4.2. The deficiency affects 7 of 7 smoke compartments.

Findings include:

1. During an observation on 8/17/16 at 11:26 a.m., both inspector's test ports for the wet sprinkler system were inspected. There was one outlet outside obstetrics south exit, and one near Med Surge south exit. Both of the outlets had an orifice of 1.5 inches and not the size of smallest sprinkler orifice.¹

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-15.4.2* Wet Pipe Systems; An alarm test connection not less than 1 in. (25.4 mm) in diameter, terminating in a smooth bore corrosion-resistant orifice, giving a flow equivalent to one sprinkler of a type having the smallest orifice installed on the particular system, shall be provided to test each waterflow alarm device for each system. The test connection valve shall be readily accessible. The discharge shall be to the outside, to a drain connection capable of accepting full flow under system pressure, or to another location where water damage will not result.

Based on observations, the facility failed to maintain the automatic sprinkler system per NFPA 13, 1999 Edition, Section 5-7.6, 5-6.5.1.2, 5-1.1 and 5-5.5.3.1. These deficiencies affect 3 of 7 main floor and 1 of 3 second floor smoke compartments.

Findings include:

1. During an observation on 8/17/16 at 12:00 p.m., the cart storage room was inspected. There was storage stacked to within 18 inches of the sprinkler head in the room.¹

2. During an observation on 8/17/16 at 12:17 a.m., the imaging work room was inspected. There were two sprinkler heads within 6 feet of each other.²

3. During an observation on 8/17/16 at 2:05 p.m., there was an open ceiling tile near the sterilizer equipment room.³

4. During an observation on 8/17/16 at 2:33 p.m., the OB nursery was inspected. There was a sprinkler head missing the escutcheon ring in the room.³

5. During an observation on 8/17/16 at 8:55 a.m., penthouse 3 was inspected. There was an air handling duct measuring 4 feet by 12 feet which was not sprinkler protected underneath.4
¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-7.6 Clearance to Storage (Standard Sidewall Spray Sprinklers), The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

² NFPA 13, 1999 Edition, Section 5-6.3.4, Minimum Distance Between Sprinklers.; Sprinklers shall be spaced not less than 6 ft (1.8 m) on center.
Exception No. 1: Sprinklers shall be permitted to be placed less than 6 ft (1.8 m) on center where the following conditions are satisfied:
(a) Baffles shall be installed and located midway between sprinklers and arranged to protect the actuating elements.
(b) Baffles shall be of noncombustible or limited-combustible material that will stay in place before and during sprinkler operation.
(c) Baffles shall be not less than 8 in. (203 mm) wide and 6 in. (152 mm) high. The tops of baffles shall extend between 2 in. and 3 in. (51 mm and 76 mm) above the deflectors of upright sprinklers. The bottoms of baffles shall extend downward to a level at least even with the deflectors of pendent sprinklers.
Exception No. 2: In-rack sprinklers shall be permitted to be placed less than 6 ft (1.8 m) on center.
Exception No. 3: Old-style sprinklers protecting fur storage vaults shall be permitted to be placed less than 6 ft (1.8 m) on center.

³ NFPA 13, 1999 Edition, Section 5.1.1; The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: 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.

4 NFPA 13, 1999 Edition, 5-5.5.3.1; Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.
Exception: Obstructions that are not fixed in place such as conference tables.

Based on observation, the facility failed to properly inspect a fire extinguisher in accordance with NFPA 10, 1998 Edition, Section 4-3.4.2. This deficiency affects the laboratory staff.

Findings include:

1. During an observation on 8/18/16 at 1:42 p.m., the laboratory was inspected. There was a portable fire extinguisher mounted to the wall which had not been inspected for the month of July 2016.¹

¹ NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 4-3.4.2; At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

Based on observation, the facility failed to assure that portable heaters were not in use in resident care and treatment areas per NFPA 101, 2000 Edition, Section 18.7.8. This deficiency has the potential to affect all patients/residents in 1 of 7 smoke compartments.

The findings include:

1. During an observation on 8/18/16 at 8:25 a.m., the infusion lab was inspected. There was an oil-filled heater in each of the two patient treatment rooms.¹

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 18.7.8 Portable Space-Heating Devices; Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).

Based on observation, the facility failed to ensure the means of egress were continuously maintained free of all obstructions to full instant use in the case of fire or other emergency in accordance with NFPA 101, 2000 Edition, Section 7.1.10.1 and 7.2.1.4.5. This deficiency affects 1 of 7 smoke compartments.

Findings include:

1. During an observation on 8/17/16 at 1:58 p.m., the sterile processing room was inspected. There was a container stored near the corridor door which impeded the door from opening fully.¹ ²

¹ NFPA 101, 2000 Edition, Section 7.1.10.1; Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

² NFPA 101, 2000 Edition, Section 7.2.1.4.5; The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the door in motion, and 15 lbf (67 N) to open the door to the minimum required width. Opening forces for interior side-hinged or pivoted-swinging doors without closers shall not exceed 5 lbf (22 N). These forces shall be applied at the latch stile.
Exception No. 1: The opening force for existing doors in existing buildings shall not exceed 50 lbf (222 N) applied to the latch stile.
Exception No. 2: The opening forces for horizontal sliding doors shall be as provided in Chapters 22 and 23.
Exception No. 3: The opening forces for power-operated doors shall be as provided in 7.2.1.9.

Based on observation, the facility failed to store oxygen cylinders in accordance with the standards of NFPA 99, 1999 Edition, Section 4-3.5.2.1.¹ This deficiency affects one room of the facility.

Findings include:

1. During an observation on 8/18/16 at 1:31 p.m., the supply closet was inspected. There were two E-sized oxygen tanks standing in the closet and were not restrained from falling over.¹

¹ NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 4-3.5.2.1; Gases in Cylinders and Liquefied Gases in Containers - Level 1, (a) Handling of Gases; requires administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility. (b)Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed: 27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Based on observation, the facility failed to maintain power strips in accordance with Center for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC. The deficiency affects the main floor.

Findings include:

1. During an observation on 8/19/16 at 9:59 a.m., the physicians office was inspected. There was a power strip dangling by the cord plugged into it.¹

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

Based on observation, the facility failed to ensure that alcohol-based hand rub (ABHR) dispensers were not installed directly over an ignition source per CMS Survey & Certification Policy S&C-05-33. This deficiency affect one room of the building.

Findings include:

1. During an observation on 8/18/16 at 1:59 p.m., the physical therapy room was inspected. There were two Alcohol Based Hand Rub (ABHR) stations mounted over outlets in the room.¹

¹ CMS interpretations under Survey & Certification (S&C)-05-33 policy issued on June 9, 2005, states ABHR dispensers shall meet the NFPA amendment to the 2000 Life Safety Code regarding the installation of ABHR dispensers in exit corridors and on interior walls. The Certification Bureau enforces that ABHR dispensers be offset by at least one inch and not mounted directly above any electrical source.