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Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this code. 8.3.3.1.

Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 7.2.1.15.2

Review of documentation and interview with staff determined fire rated door assemblies had not been inspected in the past year.

Failure to inspect and test fire rated door assemblies increases the risk of injury or death due to fire.

This deficiency affected all fire rated door assemblies throughout the facility.

The facility failed to maintain the means of egress in accordance with Chapter 7.

1) During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open. 7.2.1.4.3.1

Observation determined the corridor door to the Linen Storage Room on the upper level opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened.

Failure to maintain the means of egress free of obstructions at all times increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous corridor doors in the means of egress throughout the facility.

2) Means of egress must be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. The width of means of egress shall be measured in the clear at the narrowest point of the exit component under consideration. Exception: Projections not more than 4 1/2 in. (114 mm) on each side shall be permitted at 38 in. (965 mm) and below. 7.1.10.1, 7.3.2.2

In addition to the requirements of the Life Safety Code, health care facilities must comply with the requirements of the ADA, including the requirements for protruding objects. The 2010 Standards for Accessible Design generally limit the protrusion of wall-mounted objects into corridors to no more than 4 inches from the wall when the object's leading edge is located more than 27 inches, but not more than 80 inches, above the floor. This requirement protects persons who are blind or have low vision from being injured by bumping into a protruding object that they cannot detect with a cane. Although the Life Safety Code allows 6-inch projections, under the ADA, objects mounted above 27 inches and no more than 80 inches high can only protrude a maximum of 4 inches into the corridor beyond a detectable surface mounted less than 27 inches above the floor (except for certain handrails which may protrude up to 4 1/2 in.)

Observation determined:

a) A fixed heater that was located in the corridor by the Nurse Station extended approximately six (6) inches from the corridor wall and protruded into the exit corridor.
b) A fixed heater that was located in the corridor by Activity Room extended approximately six (6) inches from the corridor wall and protruded into the exit corridor.
c) A fixed heater that was located in the corridor by the elevator on the lower level extended approximately six (6) inches from the corridor wall and protruded into the exit corridor.
d) A speaker that was located in the corridor by the Activity Room mounted at a height of seventy-two (72) inches, extended approximately eleven (11) inches from the corridor wall and protruded into the exit corridor.
e) An exit sign that was located in the stairway by the northeast exterior door mounted at a height of seventy-two (72) inches, extended approximately twelve (12) inches from the corridor wall and protruded into the exit corridor.

The corridor was eight (8) feet wide at all locations.

Failure to maintain the means of egress to be available at all times increases the risk of death or injury due to fire.

The deficiency affected egress from two (2) of two (2) smoke compartments in the facility.

The facility failed to provide a one-hour fire resistance rated stair enclosure.

Observation determined the walls of the east stair enclosure stopped at the membrane ceiling and were not extended to the roof deck.

Failure to provide one-hour fire resistance rated vertical openings increases the risk of death or injury due to fire.

This deficiency affected one (1) of three (3) vertical shafts in the building.

Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 19.3.4.1

A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm and Signaling Code. 9.6.1.3. 2010 NFPA 72, 14.1.1

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

Fire alarm system batteries shall be subjected to a load voltage test semiannually. NFPA 72, 14.4.2.2 item 5(e).

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. A load voltage test of the fire alarm system batteries was done during the annual inspection by an outside company on 03/20/2019. Records did not indicate any other load voltage test on the fire alarm system batteries in the past year.

Failure to install, test and maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected one (1) of two (2) required load voltage tests of the fire alarm batteries in the past year. The fire alarm system serves the entire facility.

The facility failed to ensure smoke detectors were installed, maintained, inspected and tested in accordance with NFPA 72, National Fire Alarm and Signaling Code.

1) In the absence of specific performance-based design criteria, smooth ceiling smoke detector spacing shall be a nominal 30 ft. The distance between detectors shall not exceed their listed spacing, and there shall be detectors within a distance of one-half the listed spacing, measured at right angles from all walls or partitions. 19.3.4.5.1, 9.6.2.10.1.1, NFPA 72: 17.7.3.2.3.1

Observation determined the smoke detector in the corridor by the Northeast Mechanical Room on the lower level was more than 15 ft from the wall at the end of the corridor.

2) In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow or closer than 36 in. from an air supply diffuser or return air opening. 19.3.4.5.1, 9.6.2.10.1.1, NFPA 72 17.7.4.1

Observation determined the smoke detector in the corridor by the Housekeeping Storage Room was installed within 36 in. of an air supply diffuser.

Failure to install the smoke detection system as required increases the risk of death or injury due to fire.

This deficiency affected two (2) of numerous smoke detectors in the facility. The smoke detection system serves the entire facility.

Health care facilities shall be protected throughout by an approved, supervised automatic fire sprinkler system. 19.3.5.3, 19.3.5.4, 9.7.1.1(1)

The facility failed to install the automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

The maximum distance permitted between sprinklers shall be based on the centerline distance between adjacent sprinklers. The maximum distance shall be measured along the slope of the ceiling. The maximum distance permitted between sprinklers shall comply with the value indicated in the applicable section for each type or style of sprinkler. Standard pendent and upright spray sprinklers shall be spaced not less than 6 ft on center.

Sprinklers shall be permitted to be placed less than 6 ft on center where the following conditions are satisfied:
(1) Baffles shall be installed and located midway between sprinklers and arranged to protect the actuating elements.
(2) Baffles shall be of noncombustible or limited-combustible material that will stay in place before and during sprinkler operation.
(3) Baffles shall be not less than 8 in. wide and 6 in. high.
(4) The tops of baffles shall extend between 2 in. and 3 in. above the deflectors of upright sprinklers.
(5) The bottoms of baffles shall extend downward to a level at least even with the deflectors of pendent sprinklers.
NFPA 13 8.5.3.1, 8.6.3.4, 8.6.3.4.1, 8.6.3.4.2

Observation determined:

1) Two (2) sprinklers in the Activity Room were closer than the minimum of 6 ft apart.

2) Two (2) sprinklers in the Soiled Linen Room Closet were closer than the minimum of 6 ft apart.

Failure to install the automatic sprinkler system in accordance with NFPA 13 increases the risk of injury or death due to fire.

The deficiency affected two (2) of numerous locations protected by the automatic sprinkler system, which serves the entire facility.

Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. 19.7.6, 4.6.12, NFPA 25 4.1.4.1

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25.

Record review and observation determined:

1) The control valves and the gauges of the automatic sprinkler system had not been inspected monthly.

2) Quarterly flow tests of the automatic sprinkler system were not completed as required. Records did not indicate flow tests were conducted during the third and fourth quarters of 2018 and the first quarter of 2019.

3) A sprinkler pipe hanger in the Northwest Mechanical Room was pulled loose from its anchor point on the ceiling.

4) The Elevator Equipment Room was missing ceiling tiles that could delay the activation of the sprinkler system.

Failure to inspect, test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

The deficiency affected the complete automatic sprinkler system, which serves the entire facility.

Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. 19.3.6.1, 19.3.6.1(1)

Smoke compartments protected throughout by an approved supervised automatic sprinkler system shall be permitted to have spaces that are unlimited in size and open to the corridor, provided that all of the following criteria are met:
a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers.
c) The open space is protected by an electrically supervised automatic smoke detection system or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses station or similar space.
d) The space does not obstruct access to required exits.

The facility failed to separate other areas from corridors in accordance with 19.3.6.1.

Observation determined the Ice Room that was open to the corridor did not have automatic smoke detection and was not located to allow direct supervision by the facility staff from a nurses' station or similar space.

Failure to separate corridors from other areas in accordance with 19.3.6.1 increases the risk of death or injury due to fire.

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

1) The facility failed to ensure electrical wiring and electrical equipment met the requirements of NFPA 70, National Electrical Code. 19.5.1.1, 9.1.2

a) Observation determined there was an open electrical junction box on the ceiling in the Medication Room.

b) Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26(A)(1), (A)(2), and (A)(3). The depth of the working space in the direction of live parts shall not be less than 3 ft. Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed. The width of the working space in front of the electrical equipment shall be the width of the equipment or 30 in., whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

The work space shall be clear and extend from the grade, floor, or platform to a height of 6 1/2 ft or the height of the equipment, whichever is greater. Within the height requirements of this section, other equipment that is associated with the electrical installation and is located above or below the electrical equipment shall be permitted to extend not more than 6 in. beyond the front of the electrical equipment.

Required working space shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded. NFPA 70, 110.26(A), 110.26(B)

Observation determined a refrigerator was located adjacent to the front of electrical panel in the Nutrition Room.

c) Ground-fault circuit-interruption for personnel shall be provided as required. The ground-fault circuit-interrupter shall be installed in a readily accessible location. All 125-volt, single-phase, 15- and 20-ampere receptacles located in bathrooms, kitchens and where receptacles are installed within 6 ft. of the outside edge of the sink shall have ground-fault circuit-interrupter protection for personnel. NFPA 70 210.8, 210.8(B)(1), 210.8(B)(2), 210.8(B)(5)

Observation determined:

1) Two (2) electrical receptacles in the Emergency Room within 6 ft. of a sink were not ground-fault circuit-interrupter protected.
2) One (1) electrical receptacle in the Bathroom by the Laundry Room was not ground-fault circuit-interrupter protected.
3) Two (2) electrical receptacles in the Lab Bathroom were not ground-fault circuit-interrupter protected.
4) Five (5) electrical receptacles in the Pharmacy within 6 ft. of a sink were not ground-fault circuit-interrupter protected.

Failure to provide electrical wiring and equipment in accordance with NFPA 70 increases the risk of injury or death due to fire.

The deficiency affected twelve (12) of numerous components of the electrical system in the facility.

2) Gas-fired dryers must be supplied with air for combustion in accordance with NFPA 54, National Fuel Gas Code. 33.3.6.2.1, 9.2.2, NFPA 54 9.3.1.1, 9.3.3

The facility failed to ensure gas-fired dryers were supplied with air for combustion in accordance with NFPA 54.

Air for combustion, ventilation, and dilution of flue gases for appliances installed in buildings shall be obtained by application of one of the methods covered in 9.3.2 through 9.3.6. Where the requirements of 9.3.2 are not met, outdoor air shall be introduced in accordance with methods covered in 9.3.3 through 9.3.6.

Outdoor combustion air shall be provided through opening(s) to the outdoors in accordance with the methods in 9.3.3.1 or 9.3.3.2.

The minimum dimension of air openings shall not be less than 3 in.

9.3.3.1 Two Permanent Openings Method.
Two permanent openings, one commencing within 12 in. of the top of the enclosure and one commencing within 12 in. of the bottom of the enclosure, shall be provided. The openings shall communicate directly, or by ducts, with the outdoors or spaces that freely communicate with the outdoors, as follows:
1) Where directly communicating with the outdoors or where communicating to the outdoors through vertical ducts, each opening shall have a minimum free area of 1 sq.in./4000 Btu/hr of total input rating of all appliances in the enclosure.
2) Where communicating with the outdoors through horizontal ducts, each opening shall have a minimum free area of 1 sq.in./2000 Btu/hr of total input rating of all appliances in the enclosure.

9.3.3.2 One Permanent Opening Method.
One permanent opening, commencing within 12 in. of the top of the enclosure, shall be provided. The appliance shall have clearances of at least 1 in. from the sides and back and 6 in. from the front of the appliance. The opening shall directly communicate with the outdoors or shall communicate through a vertical or horizontal duct to the outdoors or spaces that freely communicate with the outdoors and shall have a minimum free area of the following:
1) 1 sq.in./3000 Btu/hr of the total input rating of all appliances located in the enclosure.
2) Not less than the sum of the areas of all vent connectors in the space.

Observation determined the facility failed to provide air for combustion for two (2) of two (2) gas-fired dryers in the Laundry.

Failure to ensure gas-fired dryers are supplied with air for combustion in accordance with NFPA 54 increases the risk of death or injury due to fire.

This deficiency affected two (2) of two (2) gas-fired dryers in the facility.

Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:

(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.

(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating.

Diesel-powered EPS installations that do not meet the requirements shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours. NFPA 99 6.4.4.1.1.4, NFPA 110 8.4.1, 8.4.2, 8.4.2.3

The facility failed to ensure the emergency generator was in compliance with NFPA 99 and NFPA 110.

Review of generator test records did not indicate:

1) The minimum exhaust temperature provided by the manufacturer was achieved or the monthly exercise of the diesel generator loaded the generator to at least 30% (60 kW) of the nameplate rating. The nameplate rating of the generator was 200 kW.

The facility did not perform annual supplemental load exercises as required when diesel generators are not loaded to 30% of nameplate rating or manufacturer's recommended minimum exhaust gas temperatures were achieved during the required monthly exercises.

2) The monthly testing of the emergency generator was conducted for a minimum of 30 minutes for all months during the past year.

Failure to inspect and maintain emergency generators in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.

Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standards for Health Care Facilities. 19.3.2.4

Electrical devices should be physically protected, such as by use of a protective barrier around the electrical devices, or by location of the electrical device such that it will avoid causing physical damage to the cylinders or containers. For example, the device could be located at or above 1.5m (5 ft) above finished floor or other location that will not allow the possibility of the cylinders or containers to come into contact with the electrical device as required by this section. NFPA 99, A.5.1.3.3.2(5)

In oxygen storage rooms containing more than 300 cu. ft. of gas, all electrical wall fixtures must be physically protected or located at least five (5) feet above the floor.

The facility failed to ensure nonflammable medical gas equipment and systems were in compliance with NFPA 99.

Observation determined the Oxygen Storage Room on the lower level contained over 300 cu. ft. of oxygen and had a light switch that was unprotected and installed less than five (5) feet above the floor.

This deficiency affected one (1) of two (2) oxygen storage rooms in the facility.