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Based on observation, the facility failed to ensure the fire protective properties of the structure were maintained in accordance with NFPA 101. Failure to maintain compartmentation and seal penetrations in rated assemblies, has the potential to allow fire, smoke and dangerous gases to bypass active systems and travel between compartments. This deficient practice affected patients, staff and visitors on the date of the survey.

Findings include:

During the facility tour conducted on 2/15/23 from 11:00 AM - 3:00 PM and 2/16/23 from 9:00 - 11:00 AM, observation of the facility structure revealed the following:

- In the basement boiler room, observation of an east to west lateral supporting wall revealed an approximately ten-inch unsealed through penetration of the wall, exposing a unprotected area of a support beam for the floor above.
- In the basement IT room, three(3) approximately four-inch unsealed conduits were observed penetrating into the floor above.
- In the basement electrical storage, an unsealed approximately two-inch diameter membrane penetration was observed above the door, exposing the interior wall cavity.
- In the second floor TDR closet, three(3) ceiling tiles were missing ranging from two-foot by two-foot in size, to two-foot by three-inches in size. The area above the suspended ceiling was not provided with active protection systems.

Actual NFPA standard:

19.1.6.1 Health care occupancies shall be limited to the building construction types specified in Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7. (See 8.2.1.)

8.2 Construction and Compartmentation.
8.2.1 Construction.
8.2.1.1 Buildings or structures occupied or used in accordance with the individual occupancy chapters, Chapters 11 through 43,

Based on observation, the facility failed to ensure fire suppression system pendants were maintained free of obstructions in accordance with NFPA 25. Failure to maintain suppression system pendant free of obstructing foreign materials, has the potential to hinder system response in a fire event. This deficient practice affected staff and visitors on the date of the survey.

Findings include:

During the facility tour conducted on 2/15/23 from 11:00 AM - 3:00 PM, observation of room 112, the removed elevator control room in the basement, revealed the upright pendant at the ceiling level was coated with the fibrous cement compound used for protecting the structural steel of the building.

Actual NFPA standard:

5.2 Inspection.
5.2.1 Sprinklers.
5.2.1.1 Sprinklers shall be inspected from the floor level annually.
5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).

Based on observation the facility failed to ensure safe electrical installations in accordance with their listing and NFPA 70. Failure to cover live electrical connections and the use of relocatable power taps (RPTs) or plug adapters as a substitution for the direct wiring of the facility, has the potential to increase the risk of arc fires or electrical shock. This deficient practice affected patients, staff and visitors on the date of the survey.

Findings include:

During the facility tour conducted on 2/15/23 from 11:00 AM - 3:00 PM and 2/16/23 from 9:00 - 11:00 AM, observation of installed electrical systems revealed the following:

- The EVS office was using a RPT to supply power to a microwave and a refrigerator.
- Both purchasing offices in the basement were using a RPT to supply power to a refrigerator.
- The Pharmacy office was using a non-grounded plug adapter to supply power to a coffee maker from a RPT.
- The Pharmacy reception was using a RPT to supply power to a toaster.
- The second-floor staff lounge was using a 3-1 multiple plug adapter to supply power to a water cooler and a microwave.
- An above the ceiling inspection at the loading dock revealed two(2) four-inch square junction boxes without their protective covers and exposed live electrical wiring.

Actual NFPA standard:

NFPA 70

110.27 Guarding of Live Parts.
(A) Live Parts Guarded Against Accidental Contact.
Except as elsewhere required or permitted by this Code, live parts of electrical equipment operating at 50 volts or more shall be guarded against accidental contact by approved
enclosures or by any of the following means:
(1) By location in a room, vault, or similar enclosure that is accessible only to qualified persons.
(2) By su