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Based on observation and interview the facility staff failed to maintain a fire resistance rating for the construction of the ceiling by having a penetration through the ceiling.

Penetrations through ceilings reduce or eliminate the fire resistance of the ceiling and create a condition conducive to the passage of smoke, fire, and heat during a fire.

Finding:

On 4/5/17 at 3:45 p.m., the evaluator observed that there was a 2 inch diameter penetration through the ceiling of the materials management room located in the basement.

During an interview at the same time as the observation the Facility Manager acknowledged the penetration through the ceiling and stated that the penetration would be sealed.

NFPA 101 Life Safety Code 2012 Edition

7.2.1.8.1* A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3.

This Code was not met as evidenced by:

Based on observation and interview, the facility failed to ensure that five self-closing corridor doors were not obstructed from closing.

Self-closing doors that are obstructed from closing provide a condition conducive to the transfer of smoke, heat, gases, and fire during a fire emergency.

Finding:

On 4/5/17 at 3:30 p.m., the 20 minute fire rated self-closing corridor doors of the Dietary and Purchasing Manager offices, Telemedicine suite, Exam room 5 and 6, and the physicians' office, were held open with kick down door holders installed in front of the doors.

During an interview at the same time as the observation, the Facility Manager acknowledged that the self-closing doors were being held open, and stated that the door holders would be removed.

NFPA 72 National Fire Alarm and Signaling Code 2010 edition

14.4.2.2 Systems and associated equipment shall be tested according to Table 14.4.2.2.

Table 14.4.2.2 Test Methods
Device
1. Control equipment
Method
At a minimum, control equipment shall be tested to verify correct receipt of alarm, supervisory, and trouble signals (inputs); operation of evacuation signals an auxiliary functions (outputs); circuit supervision, including detection of open circuits and ground faults; and power supply supervision for detection of loss of ac power and disconnection of secondary batteries.

14.4.5 Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.

Table 14.4.5 Testing Frequencies
6. Batteries - Fire Alarm Systems
(d) Sealed lead-acid type
(1) Charger test (Replace battery within 5 years after manufacture or more frequently as needed.)

7. Power supply - public emergency alarm reporting systems
(c) Sealed lead-acid type batteries
(1) Charger test (Replace battery within 5 years after manufacture or more frequently as needed.)

This Code was not met as evidenced by:

Based on observation and interview, that facility failed to ensure the fire alarm system was maintained.

Maintenance of the fire alarm system assists in ensuring that the fire alarm system will function as designed in the event of a fire emergency.

Findings:

1) On 4/5/17 at 9:29 a.m., during a test of the fire alarm system by the fire alarm technician, one of two sealed lead acid batteries in the #2 power supply cabinet located in the dirty utility room was tested with a cell checker. The results were red lights lighted in the fail section of the device with a reading of 70%.

During an interview at the same time as the observation, the technician stated that battery tested was bad, and that if one battery was bad they both were bad. The technician also stated that the batteries in the #2 power supply cabinet controlled the outputs to the strobes and chimes.

2) On 4/5/17 at 9:35 a.m., during a test of the fire alarm system by the fire alarm technician, a sealed lead acid battery in the fire alarm dialer panel in the basement was dated March 7, 2012. The battery was a month over due to be replaced.

During an interview at the same time as the observation, the technician stated that battery needed to be replaced. The technician also stated that the battery dialer panel controlled communications to the central monitoring station.

3) On 4/5/17 at 9:35 a.m., during a test of the fire alarm system by the fire alarm technician, testing by activating the smoke detector at a bathrooom in the clinic resulted in the signal erroneously adressed as an activation of a smoke detector in the mechanical room.

1.) NFPA 13: Standard for the Installation of Sprinkler Systems 2010 Edition

8.5.6.1 Unless the requirements of 8.5.6.2, 8.5.6.3, 8.5.6.4, 8.5.6.5 are met the clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

This Standard was not met as evidenced by:

Based on observation the facility staff failed to maintain sprinklers in accordance with NFPA 13, by having an obstruction less than 18 in. below a sprinkler deflector.

Continuous and non-continuous avoidable obstructions can prevent the proper sprinkler discharge pattern from developing and reaching the protected hazard. In the event of a fire emergency, unobstructed areas below sprinkler deflectors help assure sprinkler suppression coverage as designed.

Finding:

On 4/4/17 at 4:38 p.m., the evaluator observed that there was storage of supplies stored 3 inches from the sprinkler head deflector in the clean storage closet.

During an interview at the same time as the observation the Facility Manager stated that the top shelf would have to be cut off.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition

5.4.1.8* Sprinklers shall not be altered in any respect or have any type of ornamentation, paint, or coatings applied after shipment from the place of manufacture.

This Standard was not met as evidenced by:

Based on observation and interview the facility staff failed to maintain a sprinkler escutcheon in place.

Sprinklers maintained per their listings help ensure they work as designed during a fire emergency.

Finding:

On 4/5/17 at 8:24 a.m., one of three sprinkler heads in the Activity room was missing its escutcheon.

During an interview at the same time as the observation the Facility Manager acknowledged that the escutcheon was missing.

3.) NFPA 13: Standard for the Installation of Sprinkler Systems 2010 edition

6.7.4.1 All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs.

6.7.4.3 The control valve sign shall identify the portion of the building served.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition

13.3.1* Each control valve shall be identified and have a sign indicating the system or portion of the system it controls.

13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.

13.3.2.2* The valve inspection shall verify that the valves are in the following condition:
(6) Provided with applicable identification

This Standard was not met as evidenced by:

Based on observation and interview the facility failed to provide control valve signs that were legible and present.

The deficiency had the potential of not providing adequate valve identification to the fire department during emergency and periodic inspections.

Findings:

On 4/5/17 at 9:03 a.m., control valve signage at the OS&Y (outside stem & yoke) was sun faded and illegible, and the address signage that identifies what portion of the building the OS&Y serves was missing.

During an interview at the same time as the observation the Facility Manager acknowledged that the valve identification sign was sun faded and there was no address signage identifying what portion of the building the OS&Y served.

Based on observation and interview, the facility staff failed to ensure 2 doors protecting sleeping room corridor openings, and 1 office corridor opening held closed, and that corridor door to surgery hallway closed.

The deficiency created a condition conducive to the transfer of smoke, heat, gases, and fire during a fire emergency.

Findings:

1. On 4/5/17 at 3:06 p.m., the corridor doors of sleeping rooms 4, 5, and the COO's office failed to hold closed.

During an interview at the same time as the observation, the Facility Manager acknowledged that the doors failed to hold closed, stated that the latches needed to be adjusted, and that he would fix the doors so they hold closed.

2. On 4/5/17 at 3:30 p.m., the corridor door to the surgery hallway failed to close. The door remained open 4 inches.

During an interview at the same time as the observation, the Facility Manager acknowledged that the doors failed to close and stated that a metal plate installed on the door was what was keeping the door from closing.