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Based on observation and interview, the Facility failed to maintain a 2-hour separation is provided in accordance with 8.2.1.3.

Multiple Occupancies - Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows:
* The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1
* The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3



FINDINGS INCLUDE:

On facility tour between 10:00 AM and 1:00 PM on 03/08/2017, observation revealed the 2 hour separation between the hospital and nursing home in the kitchen hallway was observed with an open penetration around a water pipe above the lay-in ceiling.

This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.

Based on observation and interview, the Facility failed to be in accordance with Chapter 7, which states, all means of egress is to be continuously maintained free of all obstructions to full use in case of emergency.


Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

FINDINGS INCLUDE:

On facility tour between 10:00 AM and 1:00 PM on 03/08/2017, observation during the inspection revealed, the internal stairwell and employee entrance were observed with items being stored within the exit pathway. All aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency.

NOTE: All exits throughout the hospital need to be checked daily to ensure compliance.


This deficient practice was verified by the Facility Maintenance Director.

Based on observation and interview, the Facility failed to maintain the fire alram sysytem in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code.

Fire Alarm System - Installation
A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity.
18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8.


FINDINGS INCLUDE:

On facility tour between 10:00 AM and 1:00 PM on 03/08/2017, observation during the inspection revealed, the overnight doctor sleeping room was observed without a smoke alarm with a sounder board and strobe light.

This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to provide a current and accurate Fire Alarm Out of Service Policy.

Fire Alarm - Out of Service
Where required fire alarm system is out of services for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
9.6.1.6

FINDINGS INCLUDE:

On facility tour between 10:00 AM and 1:00 PM on 03/08/2017, documentation review revealed that the Out of Service Policy for the Fire Alarm System does not have current Staff/Fire Marshal contact information.

This deficient practice was verified by the Facility Maintenance Director.

Based on observation and interview, the Facility failed to ensure that fire sprinklers were kept from obstructions that could effect the operation in accordance with NFPA 13.


Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

FINDINGS INCLUDE:

On facility tour between 10:00 AM and 1:00 PM on 03/08/2017, observation revealed, combustible items were observed being stored under the conveyor in the Storeroom. The area under the conveyor is not protected by fire sprinklers.

This deficient practice was verified by the Facility Maintenance Director.

Based on documentation review and interview, the Facility failed to provide a current and accurate Fire Sprinkler Out of Service Policy.

Sprinkler System - Out of Service
Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service.
18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25)

FINDINGS INCLUDE:

On facility tour between 10:00 AM and 1:00 PM on 03/08/2017, documentation review revealed that the Out of Service Policy for the Fire Sprinkler System does not have current Staff/ Fire Marshal contact information and the 10 hour out of service time needs to be updated.

This deficient practice was verified by the Facility Maintenance Director.