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The facility failed to ensure corridor doors were equipped with automatic latching hardware suitable for keeping the door closed and resistant to the passage of smoke.

Observation determined the corridor door to the Womens Employee Locker Room did not latch into the frame.

Failure to ensure corridor doors are provided with suitable means for keeping the door closed increases the risk for death or injury due to fire.

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

The facility failed to ensure doors to hazardous areas in fully sprinklered existing health care occupancies were equipped with self-closing/automatic latching hardware.

Observation determined:
1) The corridor door to the Storage Room in the 100 Wing did not self-close to latch into the door frame.
2) The corridor doors to the Soiled Linen Rooms in the 100 and 200 Wings were not equipped with self-closing devices.

Failure to ensure doors to hazardous areas self-close and latch to the door frame increases the risk or death or injury due to fire.

This deficiency affected three (3) of eleven (11) hazardous areas in the facility.

The administration of health care facilities is to develop and distribute to all supervisory personnel written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees are to be periodically instructed and kept informed with respect to their duties under the plan.

Review of policies/procedures indicated the facility failed to provide a written fire emergency plan that clearly indicates safe areas of refuge in the event of a fire.

Failure to provide a plan for the protection of all patients and for their evacuation in the event of a fire increases the risk of death or injury due to fire.

The fire emergency plan affects the entire facility.

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

Review of the fire alarm test records indicated:
1) The facility failed to conduct an annual fire alarm test. The last record of a fire alarm system test was done by an outside company on 7/30/13, exceeding 12 months.
2) The semiannual load voltage tests of the sealed lead acid batteries were not performed as required. Records did not indicate a load voltage test of the fire alarm system batteries in the past 12 months. Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 table 7-3.2 item 6.d.3.

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

This deficiency affected numerous tests of the fire alarm system. The fire alarm system serves the entire building.

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.

All backflow devices installed in fire protection water supply shall be tested annually at the designed flow rate of the fire protection system, including hose stream demands, if appropriate.
Exception: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be conducted at the maximum flow rate possible.



Observation determined:
1) Two (2) 2 'x 2 ' open grates were installed in place of ceiling tile in the Lab. The grates were not dampered.
2) On 10/27/2014 no record of the required annual back flow preventer test was available.

The deficiency affected one of numerous required tests of the automatic sprinkler system.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.5, 1998 NFPA 25 Section 9-6.2

Sprinkler record review determined:
3) The facility failed to conduct quarterly tests of the sprinkler system as required. Review of records and interview of maintenance staff determined a quarterly flow test of the automatic sprinkler system was not done in the second quarter of 2014.

The deficiency affected one (1) of four (4) quarterly tests of the automatic sprinkler system in the past year.

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

The automatic sprinkler system serves the entire building.

The facility failed to maintain the portable fire extinguishers.

Observation determined the portable fire extinguisher located in the Kitchen had a leaking hose.

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

This deficiency affected one (1) of numerous portable fire extinguishers in the facility.

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 in a hospital and records of the testing be available for review.

Review of records indicated the fire dampers were last tested and inspected by an outside company on February 4, 2008, exceeding six years.

Failure to maintain the fire dampers in accordance with NFPA 90A increases the risk of death or injury due to fire.

This deficiency affected fire dampers throughout the entire facility.

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.Maintenance of emergency generator batteries should include checking and recording the value of the specific gravity. NFPA 110, Section A-6-3.6

Record review and interview of maintenance staff determined the batteries in the emergency generator were not tested for specific gravity.

Failure to ensure the emergency generator is in compliance with 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 for the building.