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The facility failed to ensure interior wall finishes for rooms and spaces not used for corridors had a Class A or B rating.

Observation determined Styrofoam panels attached to the floor/ceiling assembly separating the first and second floors in the south Mechanical Room on the first floor. The Styrofoam panels covered approximately three fourths of the area in the room. The facility did not provide documentation this application provided an acceptable interior finish rating.

Failure to ensure fire resistive ratings on interior finish increases the risk of death or injury due to fire.

This deficiency affected one (1) of numerous rooms in the facility.

The facility failed to provide an appropriate fire protection rating on door assemblies in vertical openings. 8.2.3.2.3.1.

Observation determined the latching hardware on the stairway doors on the second floor, zone 11 and zone 12, and first floor near exit number four, was not fire rated hardware.

Failure to protect vertical openings with complying fire ratings increases the risk of death or injury due to fire.

This deficiency affected three (3) of eight (8) stairway doors.

The facility failed to separate hazardous areas from other spaces with smoke resistive partitions and self-closing and latching door assemblies.

Observation determined:
1- The double doors to the Material Management Storage Room did not self-latch into the door frame. One (1) of the two (2) doors was equipped with a manual latching device.
2- The east Laundry Room door did not self-close and latch into the door frame.
3- The corridor door to the west end of Lab did not self-close and latch into the door frame.
4- The Boiler Room had several areas around electrical conduit and low voltage wire penetrations that were not sealed to prevent the passage of smoke.

Failure to separate hazardous areas increases the risk of death or injury due to fire.

This deficiency affected four (4) of thirteen (13) hazardous areas.

A functional test must be conducted on every required emergency lighting system at 30-day intervals for a minimum of 30 seconds. An annual test must be conducted for 1 1/2-hour duration. Written records of testing must be kept by the owner for inspection by the authority having jurisdiction.

1- Review of records indicated the facility failed to conduct an annual ninety (90) minute test on three (3) of three (3) emergency battery pack lights.

2- The emergency battery pack lights in the Generator Room and Operating Room Number One failed to illuminate when tested.

Failure to maintain emergency lighting increases the risk of death or injury due to fire.

This deficiency affected two (2) of three (3) emergency battery back-up lights.

The facility failed to ensure the exit signs were displayed with continuous illumination.

Observation determined exit signs had burned out bulbs throughout the facility.

Failure to ensure exit sign illumination increases the risk of death or injury due to fire.

This deficiency affected the entire facility.

Fire drill records did not indicate that fire drills were held at unexpected times and under varying conditions.

Review of fire drill records indicated four (4) of four (4) fire drills held on the second shift were within one (1) hour of the same time of day. Three (3) of four (4) fire drills held on the third shift were within one (1) hour of the same time of day.

Failure to conduct fire drills at unexpected times increases the risk of death or injury due to fire.

This deficiency affected seven (7) of the past twelve (12) fire drills.

The facility failed to test the fire alarm system as required.

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. The annual test report did not indicate load voltage test of the batteries.

Failure to test the fire alarm system as required increases the risk of death or injury due to fire.

This deficiency affected two (2) of two (2) required load voltage tests of the batteries in the last year.

Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 table 7-3.2 item 6.d.3.

1- The facility failed to ensure smoke detectors were installed in accordance with NFPA 72.

a- Smoke detectors should not be located in a direct airflow nor closer than 3 ft. (1 m) from an air supply diffuser or return air opening. NFPA 72 A-2-3.5.1

Observation determined that the smoke detector in the Laundry Room was located approximately one (1) foot from the ceiling fan.

b- Observation determined two (2) smoke detectors located near Recovery Room 2 were covered with a plastic cover.

This deficiency affected three (3) of numerous smoke detectors in the facility.


2- Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years.

The facility failed to ensure smoke detectors were maintained, inspected and tested in accordance with the manufacturer's specifications.

Review of the fire alarm test results indicated the smoke detection system did not have sensitivity testing at frequencies in compliance with the minimum requirements of NFPA 72.

Record review indicated the sensitivity of the smoke detectors was tested in 2014 and 2010, exceeding two years.

This deficiency affected one (1) of two (2) required tests.

Failure to maintain smoke detectors as required increases the risk of death or injury due to fire.

Automatic fire sprinkler systems must be installed in accordance with NFPA 13.

The facility failed to install the automatic sprinkler system in accordance with NFPA 13 to provide adequate coverage for all portions of the building.

1- Observation determined:

a- Two (2) sprinklers were located closer than six (6) feet apart near Recovery Room 2.

b- There was not adequate coverage of sprinklers in the south Mechanical Room under the HVAC ductwork. Ductwork throughout the room was more than four (4) feet wide without sprinkler coverage under the ductwork.

2- Ordinary-temperature-rated sprinklers shall be used throughout buildings. NFPA 13, Section 5-3.1.5

The facility failed to provide ordinary-temperature-rated sprinklers throughout the facility.

Observation determined intermediate-temperature-rated sprinklers were located throughout the main Laundry Room and the first floor Elevator Equipment Room.

Failure to properly install the automatic sprinkler system increases the risk of death or injury due to fire.

This deficiency affected four (4) of numerous rooms in the facility.

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

Heat from a fire stratifies to the ceiling and travels along the ceiling to activate the sprinkler. When ceilings are removed, it delays the activation of the automatic fire sprinkler system.

Observation determined several ceiling tiles were removed throughout a Waiting Room area near Recovery Room 2. A ceiling tile was also missing in the northeast Mechanical Room next to Medical Records.

Failure to maintain the automatic sprinkler system increases the risk of death or injury due to fire.

This deficiency affected two (2) of numerous areas in the facility.

The facility failed to maintain exit corridors free of all obstructions or impediments.

Observation determined a bed, a chair, and two (2) carts were stored in the corridor near exit #2 throughout the entire survey.

Failure to maintain corridors free of obstructions increases the risk of death or injury due to fire.

This deficiency affected one (1) of nine (9) exit corridors.

The gas content of medical gas piping systems must be readily identifiable by appropriate labeling with the name and pressure of the gas contained at intervals of not more than 20 feet and at least once in each room and each story traversed by the piping system. Such labeling must be by means of metal tags, stenciling, stamping, or adhesive markers, in a manner that is not readily removable. 4-3.1.2.14. The facility failed to ensure appropriate labeling with the name and pressure of the gas contained in the copper pipes that supply oxygen to patient care areas throughout the facility.Observation determined the piping in the Oxygen Supply Room for the oxygen supply manifold had no markings or labels applied to the piping to indicate the content of the gas line.

Failure to properly label oxygen piping increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) oxygen supply manifolds in the facility.

1- Transfer switches must be subjected to a maintenance program including connections, inspection or testing for evidence of overheating and excessive contact erosion, removal of dust and dirt, and replacement of contacts when required. NFPA 110, Standard for Emergency and Standby Power Systems.

Based on record review, the facility failed to provide evidence of an annual maintenance program for the transfer switch.

Failure to maintain transfer switches increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) transfer switch.


2- Records review indicated the facility failed to maintain fire dampers in a reliable operating condition as required by NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. Fire damper testing must be performed at least every six (6) years and records of the testing be available for review.

Review of records could not verify the fire dampers had been inspected and tested.

Failure to maintain fire dampers increases the risk of death or injury due to fire.

This deficiency affected all fire dampers throughout the facility.

Maintenance of emergency generator batteries should include checking and recording the value of the specific gravity. NFPA 110, Section A-6-3.6

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.

Observation determined the battery in the emergency generator was a sealed battery. The specific gravity of the battery or water levels could not be checked.

Failure to maintain the emergency generator increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) generator battery.

The facility failed to ensure electrical wiring and electrical equipment met NFPA 70 requirements.

Observation determined:

1- Multiple power strips were being used throughout the facility for items such as microwave ovens, fans, and a toaster.

2- An electrical junction box located above the ceiling grid near Recovery Room 2 had no cover.

Failure to ensure electrical wiring meets NFPA 70 requirements increases the risk of death or injury due to fire.

This deficiency affected the entire facility.