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Based on observation and interview, the facility failed to separate mixed occupancies as required.

Findings include:

On 8/18/2014 the 2 hour fire resistance rated (FRR) construction required between health care occupancy and business occupancy was incomplete in the following areas. The business occupancy was on the first floor and the health care occupancy was on the second floor.

Stairwells - 2 each, 1 hour fire resistance rating

This was identified on the provider ' s plans. The stairwell construction was probed by the facility staff on 8/19/2014 and confirmed 1 layer of 5/8 inch gypsum board on each side of steel studs consistent with 1 hour FRR construction.

Ref: 2000 NFPA 101 Section 19.1.2.1(2)

On 8/19/2014 the 1 hour fire resistance rated (FRR) construction required between ambulatory health care occupancy (Emergency Room) and business occupancy on the first floor was incomplete as follows:

· Door to waiting area - 20 minute rating, 45 minute rating required.
· Above drop in ceiling. Incomplete above ceiling tile to floor deck above door to waiting area.

Ref: 2000 NFPA 101 Section 21.1.2.1, 8.2.3.2.3.1(2)

The Facility Engineer was present when the deficiency was identified.

Failure to maintain FRR separation as required increases the risk of death or injury due to fire.

The deficiency affected three of numerous locations requiring FRR construction.

Based on observation and interview, the facility failed to protect hazardous areas as required.

Findings include:

On 8/19/2014 room B266, soiled utility room in the surgery area was not equipped to be self-closing as required. The soiled utility room is considered a hazardous area. Doors to hazardous areas are required to be self-closing.

The Facility Engineer was present when the deficiency was identified.

Failure to protect hazardous areas as required increases the risk of death or injury due to fire.

The deficiency was one of numerous hazardous areas in the building.

Ref: 2000 NFPA 101 Section 19.3.2.1

Based on observation and interview, the facility failed to protect hazardous areas as required.

Findings include:

On 8/20/2014 the door to the oxygen storage room was unrated and was not self-closing. The oxygen storage room is considered a hazardous area. Hazardous areas are required to be protected with automatic fire sprinklers or separated with a 1 hour fire resistance rated (FRR) enclosure. Automatic fire sprinklers were not present in the building. Doors to 1 hour FRR enclosures are required to be rated 45 minute fire resistance rated and self-closing. The door closer had been disabled.

On 8/20/2014 three swinging doors to the medical records storage area were unrated and were not self-closing. The medical records storage area is considered a hazardous area. Hazardous areas are required to be protected with automatic fire sprinklers or separated with a 1 hour fire resistance rated (FRR) enclosure. Automatic fire sprinklers were not present in the building. Doors to 1 hour FRR enclosures are required to be rated 45 minute fire resistance rated and self-closing. In addition, there was also a window to the medical records storage area that does not meet the 1 hour FRR required of the enclosure. Any door hold open devices must automatically release upon smoke detection in accordance with the requirements of smoke detectors for smoke detectors for door release service in NFPA 72, National Fire Alarm Code.

The Lead Maintenance Staff was present when the deficiency was identified.

Failure to protect hazardous areas as required increases the risk of death or injury due to fire.

The deficiency affected two of numerous areas in the building.

Ref: 2000 NFPA 101 Section 39.3.2.1, 8.4, 7.2.1.8.2

Based on observation and interview, the facility failed to maintain the means of egress as required.

Findings include:

On 8/19/2014 the following doors were found be equipped with keyed locks in the direction of egress. Doors in the means of egress are not permitted to be equipped with a lock or latch that requires the use of a key in the direction of egress.
· Room A224, MSP supervisor office. Keyed deadbolt in direction of egress
The Facility Engineer was present when the deficiency was identified.

Failure to maintain the means of egress as required increases the risk of death or injury due to fire.

The deficiency affected one of numerous doors in the means of egress.

Ref: 2000 NFPA 101 Section 19.2.2.2.1, 7.2.1.5.1, 19.2.2.2.4

Based on observation and interview, the facility failed to maintain the means of egress as required.

Findings include:

On 8/20/2014 gates in the exit discharge in the means of egress using the back door of the building were equipped with pad locks. Locks or latches are not permitted to require the use of key, tool, special knowledge or effort in the direction of egress. The pad lock did not meet this requirement.

The Lead Maintenance Staff was present when the deficiency was identified.

Failure to maintain the means of egress as required increases the risk of death or injury due to fire.

Ref: 2000 NFPA 101 Section 39.2.7, 7.7.4, 7.2.1.5.1

Based on observation and interview, the facility failed to maintain the means of egress as required.

Findings include:

On 8/20/2014 the gate in the exit discharge in the means of egress using the back door of the building was equipped with a pad lock. Locks or latches are not permitted to require the use of key tool special knowledge of effort in the direction of egress. The pad lock did not meet this requirement.

The Facility Engineer was present when the deficiency was identified.

Failure to maintain the means of egress as required increases the risk of death or injury due to fire.

Ref: 2000 NFPA 101 Section 39.2.7, 7.7.4, 7.2.1.5.1

Based on observation and interview, the facility failed to conduct fire drills as required.

Findings include:

On 8/19/2014 the fire drill records showed fire drill were performed for the night shift were conducted between 1930 and 2030. Fire drills are to be conducted under varying conditions. Time in the shift is one of the conditions. The shift is 12 hours long. The night shift drills in the past year were conducted within a 1.0 hour variation or less in each shift in the past year.
Fire drills were conducted on the 12 hour shifts that nurses work. Other staff work 3 - 8 hour shifts. The swing shift (1600 - 2400) missed fire drills for 3 of 4 quarters. Fire drills are required to be conducted once per quarter per shift.
The Safety Officer was present when the deficiency was identified.

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

Ref: 2000 NFPA 101 Section 19.7.1.2

Based on observation and interview, the facility failed to test smoke detectors as required.

Findings include:

On 8/19/2014 the Facility Engineer was not able to provide documentation that smoke detector sensitivity testing had not been performed as required. Testing is required on alternate years unless previous testing shows that the detectors have remained within its listed and marked sensitivity range. The interval between testing may then be extended to 5 years. There were no records that indicated that the detectors met this requirement or the alternate year testing.
Annual functional testing had been performed on 6/12/2014 as required.
Failure to test smoke detectors and maintain records as required increases the risk of death or injury due to fire.

The deficiency affected one of two tests required of smoke detectors.

Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 Section 7-3.2.1, 7-5.2.1

Based on observation and interview, the facility failed to provide automatic fire sprinkler protection as required.

Findings include:

On 8/19/2014 two regular response sprinklers were installed in the same compartment with quick response heads near room B218 in the corridor. All sprinklers in a compartment are required to be changed to quick response heads when heads are changed.

Ref: 2000 NFPA 101 Section 19.1.6.2, 19.3.5.1, 9.7.1.1; 1999 NFPA 13 Section 5-3.1.5.2

On 8/19/2014 the automatic fire sprinkler inspectors test connection at the following locations did not terminate in a smooth bore corrosion resistant orifice giving a flow equivalent to one sprinkler of a type having the smallest orifice installed on the particular system. The inspector test connection terminated in a garden hose connection with an estimated diameter of ¾ inch. This was larger than the smallest sprinkler orifice observed in the building.

· Room A220
· Room A180
· Room C150

Ref: 2000 NFPA 101 Section 19.3.5.3, 9.7.1.1; 1999 NFPA 13 Section 5-15.4.2

On 8/19/2014 the following locations were not protected with automatic fire sprinklers as required:
· elevator machine room

Ref: 2000 NFPA 101 Section 19.1.6.2, 19.3.5.1, 9.7.1.1; 1999 NFPA 13 Section 5-1.1, 5-13.6.2

The Facility Engineer was present when the deficiency was identified.

Failure to provide automatic fire sprinklers as required increases the risk of death or injury due to fire.

The deficiency affected two of numerous locations requiring fire sprinkler protection and one of numerous features required of automatic fire sprinklers.

Based on observation and interview, the facility failed to install piped medical gas as required.

Findings include:

On 8/19/2014 medical oxygen and medical air were piped to the Biomed storage/work area. Piped medical oxygen and medical air are only permitted to be used in patient care applications.

The Facility Engineer was present when the deficiency was identified.

Failure to provide piped medical gas as required increases the risk of death or injury due to fire.

The deficiency was one of numerous locations provided with piped medical gas.

Ref: 2000 NFPA 101 Section 19.3.2.4; 1999 NFPA 99 Section 12-3.4.1, 4-3.1.1.8

Based on observation and interview, the facility failed to provide emergency power as required.

Findings include:

On 8/18/2014 the generator providing emergency power did not have a remote manual stop outside of the room housing the prime mover (diesel motor). This was confirmed on inspection on 8/19/2014.
The Facility Engineer was present when the deficiency was identified.

Failure to provide emergency power as required increases the risk of death or injury due to fire.

The deficiency was one of numerous features required of an emergency power system.

Ref: 2000 NFPA 101 Section 19.3.2.3; 1999 NFPA 99 Section 12-3.2.3, 3-4.1.1.4(a); 1999 NFPA 110 Section 3-5.5.6

Based on observation and interview, the facility failed to separate mixed occupancies as required.

Findings include:

On 8/18/2014 the 2 hour fire resistance rated (FRR) construction required between health care occupancy and business occupancy was incomplete in the following areas. The business occupancy was on the first floor and the health care occupancy was on the second floor.

Stairwells - 2 each, 1 hour fire resistance rating

This was identified on the provider ' s plans. The stairwell construction was probed by the facility staff on 8/19/2014 and confirmed 1 layer of 5/8 inch gypsum board on each side of steel studs consistent with 1 hour FRR construction.

Ref: 2000 NFPA 101 Section 19.1.2.1(2)

On 8/19/2014 the 1 hour fire resistance rated (FRR) construction required between ambulatory health care occupancy (Emergency Room) and business occupancy on the first floor was incomplete as follows:

· Door to waiting area - 20 minute rating, 45 minute rating required.
· Above drop in ceiling. Incomplete above ceiling tile to floor deck above door to waiting area.

Ref: 2000 NFPA 101 Section 21.1.2.1, 8.2.3.2.3.1(2)

The Facility Engineer was present when the deficiency was identified.

Failure to maintain FRR separation as required increases the risk of death or injury due to fire.

The deficiency affected three of numerous locations requiring FRR construction.

Based on observation and interview, the facility failed to protect hazardous areas as required.

Findings include:

On 8/19/2014 room B266, soiled utility room in the surgery area was not equipped to be self-closing as required. The soiled utility room is considered a hazardous area. Doors to hazardous areas are required to be self-closing.

The Facility Engineer was present when the deficiency was identified.

Failure to protect hazardous areas as required increases the risk of death or injury due to fire.

The deficiency was one of numerous hazardous areas in the building.

Ref: 2000 NFPA 101 Section 19.3.2.1

Based on observation and interview, the facility failed to protect hazardous areas as required.

Findings include:

On 8/20/2014 the door to the oxygen storage room was unrated and was not self-closing. The oxygen storage room is considered a hazardous area. Hazardous areas are required to be protected with automatic fire sprinklers or separated with a 1 hour fire resistance rated (FRR) enclosure. Automatic fire sprinklers were not present in the building. Doors to 1 hour FRR enclosures are required to be rated 45 minute fire resistance rated and self-closing. The door closer had been disabled.

On 8/20/2014 three swinging doors to the medical records storage area were unrated and were not self-closing. The medical records storage area is considered a hazardous area. Hazardous areas are required to be protected with automatic fire sprinklers or separated with a 1 hour fire resistance rated (FRR) enclosure. Automatic fire sprinklers were not present in the building. Doors to 1 hour FRR enclosures are required to be rated 45 minute fire resistance rated and self-closing. In addition, there was also a window to the medical records storage area that does not meet the 1 hour FRR required of the enclosure. Any door hold open devices must automatically release upon smoke detection in accordance with the requirements of smoke detectors for smoke detectors for door release service in NFPA 72, National Fire Alarm Code.

The Lead Maintenance Staff was present when the deficiency was identified.

Failure to protect hazardous areas as required increases the risk of death or injury due to fire.

The deficiency affected two of numerous areas in the building.

Ref: 2000 NFPA 101 Section 39.3.2.1, 8.4, 7.2.1.8.2

Based on observation and interview, the facility failed to maintain the means of egress as required.

Findings include:

On 8/19/2014 the following doors were found be equipped with keyed locks in the direction of egress. Doors in the means of egress are not permitted to be equipped with a lock or latch that requires the use of a key in the direction of egress.
· Room A224, MSP supervisor office. Keyed deadbolt in direction of egress
The Facility Engineer was present when the deficiency was identified.

Failure to maintain the means of egress as required increases the risk of death or injury due to fire.

The deficiency affected one of numerous doors in the means of egress.

Ref: 2000 NFPA 101 Section 19.2.2.2.1, 7.2.1.5.1, 19.2.2.2.4

Based on observation and interview, the facility failed to maintain the means of egress as required.

Findings include:

On 8/20/2014 gates in the exit discharge in the means of egress using the back door of the building were equipped with pad locks. Locks or latches are not permitted to require the use of key, tool, special knowledge or effort in the direction of egress. The pad lock did not meet this requirement.

The Lead Maintenance Staff was present when the deficiency was identified.

Failure to maintain the means of egress as required increases the risk of death or injury due to fire.

Ref: 2000 NFPA 101 Section 39.2.7, 7.7.4, 7.2.1.5.1

Based on observation and interview, the facility failed to maintain the means of egress as required.

Findings include:

On 8/20/2014 the gate in the exit discharge in the means of egress using the back door of the building was equipped with a pad lock. Locks or latches are not permitted to require the use of key tool special knowledge of effort in the direction of egress. The pad lock did not meet this requirement.

The Facility Engineer was present when the deficiency was identified.

Failure to maintain the means of egress as required increases the risk of death or injury due to fire.

Ref: 2000 NFPA 101 Section 39.2.7, 7.7.4, 7.2.1.5.1

Based on observation and interview, the facility failed to conduct fire drills as required.

Findings include:

On 8/19/2014 the fire drill records showed fire drill were performed for the night shift were conducted between 1930 and 2030. Fire drills are to be conducted under varying conditions. Time in the shift is one of the conditions. The shift is 12 hours long. The night shift drills in the past year were conducted within a 1.0 hour variation or less in each shift in the past year.
Fire drills were conducted on the 12 hour shifts that nurses work. Other staff work 3 - 8 hour shifts. The swing shift (1600 - 2400) missed fire drills for 3 of 4 quarters. Fire drills are required to be conducted once per quarter per shift.
The Safety Officer was present when the deficiency was identified.

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

Ref: 2000 NFPA 101 Section 19.7.1.2

Based on observation and interview, the facility failed to test smoke detectors as required.

Findings include:

On 8/19/2014 the Facility Engineer was not able to provide documentation that smoke detector sensitivity testing had not been performed as required. Testing is required on alternate years unless previous testing shows that the detectors have remained within its listed and marked sensitivity range. The interval between testing may then be extended to 5 years. There were no records that indicated that the detectors met this requirement or the alternate year testing.
Annual functional testing had been performed on 6/12/2014 as required.
Failure to test smoke detectors and maintain records as required increases the risk of death or injury due to fire.

The deficiency affected one of two tests required of smoke detectors.

Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 Section 7-3.2.1, 7-5.2.1

Based on observation and interview, the facility failed to provide automatic fire sprinkler protection as required.

Findings include:

On 8/19/2014 two regular response sprinklers were installed in the same compartment with quick response heads near room B218 in the corridor. All sprinklers in a compartment are required to be changed to quick response heads when heads are changed.

Ref: 2000 NFPA 101 Section 19.1.6.2, 19.3.5.1, 9.7.1.1; 1999 NFPA 13 Section 5-3.1.5.2

On 8/19/2014 the automatic fire sprinkler inspectors test connection at the following locations did not terminate in a smooth bore corrosion resistant orifice giving a flow equivalent to one sprinkler of a type having the smallest orifice installed on the particular system. The inspector test connection terminated in a garden hose connection with an estimated diameter of ¾ inch. This was larger than the smallest sprinkler orifice observed in the building.

· Room A220
· Room A180
· Room C150

Ref: 2000 NFPA 101 Section 19.3.5.3, 9.7.1.1; 1999 NFPA 13 Section 5-15.4.2

On 8/19/2014 the following locations were not protected with automatic fire sprinklers as required:
· elevator machine room

Ref: 2000 NFPA 101 Section 19.1.6.2, 19.3.5.1, 9.7.1.1; 1999 NFPA 13 Section 5-1.1, 5-13.6.2

The Facility Engineer was present when the deficiency was identified.

Failure to provide automatic fire sprinklers as required increases the risk of death or injury due to fire.

The deficiency affected two of numerous locations requiring fire sprinkler protection and one of numerous features required of automatic fire sprinklers.

Based on observation and interview, the facility failed to install piped medical gas as required.

Findings include:

On 8/19/2014 medical oxygen and medical air were piped to the Biomed storage/work area. Piped medical oxygen and medical air are only permitted to be used in patient care applications.

The Facility Engineer was present when the deficiency was identified.

Failure to provide piped medical gas as required increases the risk of death or injury due to fire.

The deficiency was one of numerous locations provided with piped medical gas.

Ref: 2000 NFPA 101 Section 19.3.2.4; 1999 NFPA 99 Section 12-3.4.1, 4-3.1.1.8

Based on observation and interview, the facility failed to provide emergency power as required.

Findings include:

On 8/18/2014 the generator providing emergency power did not have a remote manual stop outside of the room housing the prime mover (diesel motor). This was confirmed on inspection on 8/19/2014.
The Facility Engineer was present when the deficiency was identified.

Failure to provide emergency power as required increases the risk of death or injury due to fire.

The deficiency was one of numerous features required of an emergency power system.

Ref: 2000 NFPA 101 Section 19.3.2.3; 1999 NFPA 99 Section 12-3.2.3, 3-4.1.1.4(a); 1999 NFPA 110 Section 3-5.5.6