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Based on observation, interview and record review, facility staff failed to inspect, test and maintain the fire egress doors in accordance with the 2010 Editions of NFPA 80 (Standard for Fire Doors and Other Opening Protectives) and NFPA 105 (Standard for Fire Doors and Other Opening Protectives). Facility staff failed to conduct an annual inspection of the fire egress doors. The facility census was 88.

1. Review of the facility's inspection, testing and maintenance records for the 2018/2019 year showed the records did not contain documentation of an annual inspection of the fire egress doors during the 12-month period.

During an interview on 8/6/19 at 11:17 A.M., the Director of Plant Operations confirmed that facility staff did not have records of the annual inspection.

Review of NFPA 101, 2012 Edition showed the following:
-7.1.10.2.1 showed no furnishings, decorations, or other objects shall obstruct exits or their access thereto, egress therefrom, or visibility thereof.
-19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
-7.2.1.15.1* Where required by Chapters 11 through 43, the following door assemblies shall be inspected and tested not less than annually in accordance with 7.2.1.15.2 through 7.2.1.15.8:
(1) Door leaves equipped with panic hardware or fire exit hardware in accordance with 7.2.1.7;
(2) Door assemblies in exit enclosures;
(3) Electrically controlled egress doors;
(4) Door assemblies with special locking arrangements subject to 7.2.1.6.
-7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.
-7.2.1.15.3 The inspection and testing interval for fire-rated and nonrated door assemblies shall be permitted to exceed 12 months under a written performance-based program in accordance with 5.2.2 of NFPA 80, Standard for Fire Doors and Other Opening Protectives.
-7.2.1.15.4 A written record of the inspections and testing shall be signed and kept for inspection by the authority having jurisdiction.

Based on observation and facility staff interview, the facility staff failed to provide self closing devices on hazardous area doors. The facility census was 88.

1. Observation on 8/5/19, showed the following:

- The cath lab preparation area soiled linen room door did not have a self closing device. Observation showed the room contained multiple bags of soiled linen.

- The 2nd floor lab soiled linen room door did not have a self closing device. Observation showed bags of soiled linen in the room.

During an interview on 8/5/19 at 11:42 A.M., the Director of Facility Operations confirmed the observations.

19.3.2.1.1 An automatic extinguishing system, where used in
hazardous areas, shall be permitted to be in accordance with
19.3.5.9.

19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the
areas shall be separated from other spaces by smoke partitions
in accordance with Section 8.4.

19.3.2.1.3 The doors shall be self-closing or automatic-closing.

19.3.2.1.5 Hazardous areas shall include, but shall not be restricted
to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal
(242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including
repair shops, used for storage of combustible supplies and
equipment in quantities deemed hazardous by the authority
having jurisdiction

Based on observation and facility staff interview, facility staff failed to ensure areas open to the corridor contain smoke detection per NFPA 72, National Fire Alarm and Signaling Code. The facility census was 88.

Observations on 8/5/19, during the facility tour, showed the following areas open to the corridor open to the designated exit corridor. Observation showed the rooms/areas did not have smoke detector coverage:

- 2nd floor EKG room

- Behavioral Health nurses' station

- 4th floor south doctors' dictation room

- 4th floor north doctors' dictation room

- 3rd floor west doctors' dictation room

- 3rd floor south doctors' dictation room

- 3rd floor north doctors' dictation room
/
During an interview on 8/6/19 at 11:29 A.M., the Director of Plant Operations confirmed the observations.

NFPA 101, 2012 edition states "Smoke detection systems are provided in spaces open to the corridors as required by 19.3.6.1".

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

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on observation and interview, the facility failed to install a sprinkler system in accordance with the National Fire Protection Association 13, Standards for the Installation of Sprinkler Systems. These deficient practices affects all patients in the facility. The facility census was 88.

1. Observation on 8/5/19, during the facility tour, showed standard sprinkler heads and quick response sprinkler heads mounted in the same compartment in the case management corridor.

Observation on 8/5/19, during the facility tour, showed standard sprinkler heads and quick response sprinkler heads mounted in the same compartment in the morgue.

During an interview on 8/5/19, at 12:15 P.M., the Director of Facility Operations confirmed the observation.

Section 8.3.3.2 of the National Fire Protection Association (NFPA) 13 states: "Where quick-response sprinklers are installed, all sprinklers within a compartment shall be quick-response unless otherwise permitted in 8.3.3.3

2. Observation on 8/6/19, during the facility tour, showed three of three elevator hoistway pits did not have sprinkler coverage. Observation showed all three elevators employ a hydraulic elevator lift mechanism that uses a petroleum-based hydraulic fluid, which is combustible.

During an interview on 8/6/19 at 9:45 A.M., the Director of Facility Operations said that the elevator hoistway pits did not have sprinkler coverage.

Section 8.15.5.1* of NFPA 13 states: " Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit.

* The sprinklers in the pit are intended to protect against fires caused by debris, which can accumulate over time. Ideally, the sprinklers should be located near the side of the pit below the elevator doors, where most debris accumulates. However, care should be taken that the sprinkler location does not interfere with the elevator toe guard, which extends below the face of the door opening.
ASME A17.1, Safety Code for Elevators and Escalators, allow the sprinklers within 2 ft (0.65 m) of the bottom of the pit to be exempted from the special arrangements of inhibiting waterflow until elevator recall has occurred.