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Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed. 4.6.12.3

Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in the Code or as directed by the authority having jurisdiction. 4.6.12.4

Emergency illumination shall be provided for not less than 1½ hours in the event of failure of normal lighting. 7.9.2.1

Testing of required emergency lighting systems shall be permitted to be conducted as follows:

1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds.
2) The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
3) Functional testing shall be conducted annually for a minimum of 1½ hours if the emergency lighting system is battery powered.
4) The emergency lighting equipment shall be fully operational for the duration of the tests.
5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.9.3.1.1

Records review determined monthly and annual testing of the emergency battery-powered emergency lighting system was not documented.

The facility failed to ensure the emergency lighting was in proper operating condition to provide 1½ hours of emergency illumination in the event of failure of normal lighting.

Failure to test and maintain the emergency lights in accordance with NFPA 101 increases the risk of death or injury due to fire.

The deficiency affected all emergency battery back-up lights throughout the building.

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

The facility failed to ensure exit access was readily available at all times.

Observation determined the following corridor doors opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened.

1) The corridor door to the Mechanical Room by the Men's Locker Room.
2) The corridor door to the Public Restroom by the Accounting Office.
3) The corridor door to Elevator A on the 1st Floor.
4) The corridor door to the center stair enclosure.
5) The corridor door to the Public Restroom by Nuclear Medicine.
6) The corridor door to the Elevator Equipment Room in the southeast exit corridor.
7) The corridor door to the Electrical Room in the southeast exit corridor.
8) The corridor door to Elevator A on the 2nd Floor.
9) The corridor door to the West Housekeeping Closet on the 2nd Floor.

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 nine (9) of numerous corridor doors in the means of egress throughout the facility.

Illumination of means of egress shall be continuous during the time the conditions of occupancy require that the means of egress be available for use. 19.2.8, 7.8.1.2

The facility failed to ensure the illumination of the means of egress was continuously in operation or capable of automatic operation without manual intervention.

Observation determined the lights in the southeast exit corridor were controlled by a switch.

Failure to ensure illumination throughout the means of egress increases the risk of injury or death due to fire.

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

Emergency illumination shall be provided for not less than 1½ hours in the event of failure of normal lighting. 7.9.2.1

Testing of required emergency lighting systems shall be permitted to be conducted as follows:

1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds.
2) The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
3) Functional testing shall be conducted annually for a minimum of 1½ hours if the emergency lighting system is battery powered.
4) The emergency lighting equipment shall be fully operational for the duration of the tests.
5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.9.3.1.1

Records review determined monthly and annual testing of the emergency battery-powered emergency lighting system was not documented.

The facility failed to ensure the emergency lighting was in proper operating condition to provide 1½ hours of emergency illumination in the event of failure of normal lighting.

Failure to test and maintain the emergency lights in accordance with NFPA 101 increases the risk of death or injury due to fire.

The deficiency affected all emergency battery back-up lights throughout the building.

Portable fire extinguishers shall be provided in every business occupancy. Extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. Fire extinguishers shall be manually inspected when initially placed in service and thereafter either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals. 39.3.5, 9.7.4.1, NFPA 10 7.2.1.1, 7.2.1.2

The facility failed to inspect portable fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Observation determined the inspection tags on all portable fire extinguishers in the facility had not been initialed to indicate monthly inspections during April 2017.

Failure to ensure portable fire extinguishers comply with NFPA 10 increases the risk of death or injury due to fire.

The deficiency affected all portable fire extinguishers in the facility.

A door in a stair enclosure shall be self-closing and shall normally be kept in the closed position. 19.3.1.7

The facility failed to ensure doors in a stair enclosure were self-closing.

Observation determined the following stair enclosure doors failed to self-close and latch into the door frame.

1) The south door to the east stair enclosure on the 1st Floor.
2) The south door to the east stair enclosure on the 2nd Floor.
3) The north door to the east stair enclosure on the 2nd Floor.
4) The door to the south stair enclosure on the 2nd Floor.

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

This deficiency affected two (2) of four (4) stairways connecting the 1st Floor and the 2nd Floor.

Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 19.3.2.1

The facility failed to ensure hazardous areas in fully sprinklered existing health care occupancies were separated from other spaces by smoke-resisting partitions and latching doors.

Observation determined:

1) The corridor door to the Kitchen Storage Room was not equipped with a self-closing device.

2) The corridor door to IT Equipment Room with combustable storage was not equipped with a self-closing device.

3) The corridor door to the Soiled Utility Room on the 2nd Floor failed to latch into the frame.

4) The corridor door to the North Mechanical Room on the 2nd Floor had two (2) unsealed penetrations and failed to latch into the frame.

Failure to ensure hazardous areas are separated from other spaces by smoke-resisting partitions and latching doors increases the risk of death or injury due to fire.

The deficiency affected four (4) of numerous hazardous areas in the facility.

Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months. 19.3.2.5.1, 9.2.3, NFPA 96 11.2.1.

The facility failed to test and service the fire-extinguishing system serving the Kitchen exhaust hood in accordance with NFPA 96.

Record review determined the fire-extinguishing system serving the Kitchen exhaust hood was inspected and serviced on 02/07/2017 by an outside company. No other record was available in the past year.

Failure to inspect and service the fire-extinguishing system for the Kitchen exhaust hood at required intervals increases the risk of injury or death due to fire.

This deficiency affected one (1) of two (2) required inspections of the Kitchen exhaust hood fire-extinguishing system in the past year.

The power source of non-power-limited fire alarm circuits shall comply with Chapters 1 through 4, and the output voltage shall be not more than 600 volts, nominal. The fire alarm circuit disconnect shall be permitted to be secured in the "on" position. NFPA 70, National Electrical Code. 760.41(A)

The branch circuit supplying the fire alarm equipment(s) shall supply no other loads. The location of the branch-circuit overcurrent protective device shall be permanently identified at the fire alarm control unit. The circuit disconnecting means shall have red identification, shall be accessible only to qualified personnel, and shall be identified as "FIRE ALARM CIRCUIT." The red identification shall not damage the overcurrent protective devices or obscure the manufacturer's markings. NFPA 70 760.41(B)

The facility failed to ensure the fire alarm system was in compliance with NFPA 70.

Observation determined the electrical circuit breaker providing power to the fire alarm system was not secured in the "on" position.

Failure to secure the electrical circuit breaker for the fire alarm system in the "on" position increases the risk of injury or death due to fire.

This deficiency affected the entire facility. The fire alarm system serves the entire building.

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

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with NFPA 72, National Fire Alarm and Signaling Code.

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 02/06/2017. Records did not indicate any other load voltage test on the fire alarm system batteries in the past year.

Failure to 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.

1) 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. 19.3.4.5, 9.6.2.10.1.1, NFPA 72 14.4.5.3

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

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.

Test records indicated the smoke detector in the corridor by the clinic medical records area failed when tested on 02/06/2017 and had not been replaced at the time of the survey.


Failure to maintain the smoke detection system in accordance with NFPA 72 increases the risk of death or injury due to fire.

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

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, A.17.7.4.1

The facility failed to ensure the smoke detection system was in compliance with NFPA 72, National Fire Alarm and Signaling Code.

Observation determined nineteen (19) smoke detectors throughout the facility were installed within 36 in. of an air supply diffuser or return air opening.

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

This deficiency affected nineteen (19) 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), NFPA 13

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

Observation determined the sprinkler in the walk-in cooler located in the Kitchen was of intermediate-temperature classification. The walk-in cooler was not equipped with an automatic defrosting feature. NFPA 13 requires sprinklers to be ordinary-temperature classification in walk-in freezers and walk-in coolers without an automatic defrosting feature.

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

The deficiency affected one (1) of numerous sprinklers in the facility. The automatic sprinkler system 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

A main drain test shall be conducted annually at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves. In systems where the sole water supply is through a backflow preventer and/or pressure reducing valves, the main drain test of at least one system downstream of the device shall be conducted on a quarterly basis. NFPA 25, 13.2.5, 13.2.5.1

All backflow preventers installed in fire protection system piping shall be tested annually by conducting a forward flow test of the system at the designed flow rate, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer. NFPA 25, 13.6.2.1

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

Record review determined:

1) Quarterly flow tests of the automatic sprinkler system were not completed as required. Records did not indicate flow tests were conducted during the fourth quarter of 2016 and first quarter of 2017.

2) No annual back flow preventer test was conducted in the past twelve months.

3) No annual test of the automatic sprinkler system was conducted in the past twelve months.

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

5) There was a 2' x 4' open grate installed in place of ceiling tile in the northwest stair enclosure 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.

Portable fire extinguishers shall be provided in all health care occupancies. Extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 19.3.5.12, 9.7.4.1

The facility failed to install fire extinguishers in accordance with NFPA 10.

Observation determined travel distance to the nearest fire extinguisher from the south entrance on the 1st Floor exceeded 75 feet.

Failure to install fire extinguishers in accordance with NFPA 10 increases the risk of death or injury due to fire.

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

Drills shall be conducted quarterly on each shift to familiarize facility personnel with the signals and emergency action required under varied conditions. 19.7.1.6

The facility failed to conduct fire drills as required.

Fire drill records review determined:

1) No fire drills were conducted on the AM Shift during the first quarter of 2017.

2) No fire drills were conducted on the Night Shift during the second quarter in the past year.

Failure to conduct fire drills as required increases the risk of death or injury due to fire.

The deficiency affected two (2) of twelve (12) drills in the past year.

The facility failed to provide a documented risk assessment of building systems. NFPA 99, 4.2

Review of documentation and interview of staff determined the facility failed to conduct and document a risk assessment of building systems.

Failure to conduct a risk assessment of building systems increases the risk of injury or death due to fire.

This deficiency affected building systems throughout the entire facility.

1) Generator sets shall be tested 12 times a year, with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. NFPA 99 6.4.4.1.1.4, NFPA 110 8.3, 8.4.1

The facility failed to ensure the two (2) emergency generators were in compliance with NFPA 99 and NFPA 110.

Record review determined no documentation was available to indicate the generators were inspected and tested during the months of June, July, August, September, October and November 2016.

2) Generator sets shall be tested 12 times a year, with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. 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 two (2) emergency generators were in compliance with NFPA 99 and NFPA 110.

Review of generator test records did not indicate:

1) That the minimum exhaust temperature provided by the manufacturer was achieved and that the monthly exercise of the 500 kW diesel generator loaded the generator to at least 30% (150 kW) of the nameplate rating.

2) That the minimum exhaust temperature provided by the manufacturer was achieved and that the monthly exercise of the 125 kW diesel generator loaded the generator to at least 30% (38 kW) of the nameplate rating.

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 temperature during the required monthly exercises.

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 two (2) of two (2) emergency generators which provide all emergency power to the facility.

All power strips shall be used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Flexible cords and cables shall not be used for the following:

(1) As a substitute for the fixed wiring of a structure.

(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.

(3) Where run through doorways, windows, or similar openings.

(4) Where attached to building surfaces.

NFPA 70, 400-8.

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

Observation determined there was an extension cord used to provide power to an electric heat tape in the northwest stair enclosure.

Failure to ensure electrical wiring is in accordance with NFPA 70 increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous areas in the facility.