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Based on observation, the facility failed to maintain the fire resistance rating of 2-hour fire rated walls/barriers in accordance with NFPA 101, 2000 Edition, Section 8.2.3.2.4.2. This deficiency could affect 2 of 6 smoke compartments.

Findings include:

During an observation on 8/12/15 at 8:10 a.m., the two-hour barrier at the north end of the patient wing was inspected. There was an open conduit with wires running through the barrier. The conduit was not sealed on either side of the barrier.¹

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 8.2.3.2.4.2; Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observation, the facility failed to properly label a convenience exit as "No Exit", as required in NFPA 101, 2000 Edition, Section 7.10.8.1. This deficiency could affect 1 of 6 smoke compartments.

Findings include:

During an observation on 8/11/15 at 10:37 a.m., the south wing conference room was inspected. The door into the courtyard was not a required exit door but could be confused as an exit, as it lead to the outside. The door was not signed as "NO EXIT."¹

¹ NFPA 101, 2000 Edition, Section 7.10.8.1; Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads NO EXIT. Further, such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.

Based on observation, the facility failed to maintain smoke barriers per NFPA 101, 2000 Edition, Section 8.3.6.1. The deficiency could affect 2 of 6 smoke compartments.

Findings include:

During an observation on 8/12/15 at 8:29 a.m., the 1-hour fire/smoke rated wall in the nurses' break room had one unsealed penetration on the east wall of the room.¹

¹ NFPA 101, 2000 Edition, Section 8.3.6.1; Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observations, the facility failed to protect a hazardous area per NFPA 101, 2000 Edition, Section 19.3.2.1, by not securing the doors to the hazardous area with self-closing devices. These deficiencies could affect 1 of 6 smoke compartments.

Findings include:

1. During an observation on 8/11/15 at 9:13 a.m., the obstetrics storage room was inspected. The room is over 50 square feet and had no self-closer on the door.¹

2. During an observation on 8/11/15 at 11:01 a.m., the floor care room was inspected. The room is over 50 square feet, stored combustible items, and there was no self-closer on the door.¹

3. During an observation on 8/11/15 at 2:23 p.m., the outpatient surgery storage room was inspected. It is over 50 square feet, contained combustible storage, and there was no self-closer on the door.¹

¹ NFPA 101, 2000 Edition, Section 19.3.2.1; Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 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 square feet (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 square feet (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have non-rated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Based on observation and interview, the facility failed to provide for a hard surface path from an exit discharge to the public way in accordance with NFPA 101, 2000 Edition, Section 7.7.1. This deficiency had a potential to affect 1 of 6 smoke compartments.

Findings include:

During an observation on 8/11/15 at 10:06 a.m., the exit discharge from the labor and delivery area opened onto a lawn area. No hard surface path lead from this exit discharge continuously to the public way.¹

In an interview on 8/11/15 at 10:06 a.m., staff member A, director of facilities, said the Army Corp of Engineers will not allow any construction of a path near the levy of the Milk River.

The levy was observed to be 15 yards from the exit discharge.

¹ NFPA 101, 2000 Edition, Section 7.7.1; A hard surface path from the exit discharge to the public way shall be provided in climates where weather such as snow or ice or heavy rain may hinder evacuation across lawn or soil surfaces.

Based on record review and interview, the facility failed to conduct load voltage tests on the batteries of the fire alarm control panel (FACP) semi-annually, as required per NFPA 72, 1999 Edition, Table 7-3.2. The deficiency could affect 6 of 6 smoke compartments.

Findings include:

Review of the alarm system test records reflected the annual maintenance of the panel was conducted on 2/23/15, and reflected the load voltage testing had been done on the sealed lead-acid batteries of the panel. There was no documentation of load voltage testing taking place six months prior to the annual test, or up until the time of the survey.¹

During an interview on 8/10/15 at 11:15 a.m., staff member A, director of facilities, stated the load voltage tests were not being done on a semi-annual basis.

¹ NFPA 72 National Fire Alarm Code, 1999 Edition, Table 7.3.2 (6)(d)(3), requires sealed lead-acid type batteries to have a "Load Voltage Test" upon initial installation and then semiannually thereafter.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system per NFPA 13, 1999 Edition, Sections 5.1.1, 5-6.5.1.2, 5-6.3.3. and 5-6.5.3.1 These deficiencies could affect 3 of 6 smoke compartments.

Findings include:

1. During an observation on 8/11/15 at 9:09 a.m., the bathroom in patient room 128 was inspected. The sprinkler head in the bathroom was measured to be three inches from the light fixture. The light fixture was also lower than the deflector of the sprinkler head.¹ ²

2. During an observation on 8/11/15 at 9:56 a.m., the patient hall mechanical room was inspected. There was an air handling duct measure four feet by eight feet with no sprinkler coverage underneath.³

3. During an observation on 8/11/15 at 2:45 p.m., the sterile corridor was inspected. There was a sprinkler head in the middle of the corridor that was up inside the escutcheon ring, the spray of the head would be completely blocked in all directions from the head.¹ ²

4. During an observation on 8/11/15 at 2:45 p.m., a sprinkler head in a storage portion of the sterile corridor was measured to be two inches from the wall.4

In an interview on 8/12/15 at 10:20 a.m., staff member A, director of facilities, said the sprinkler was only about two inches from the wall.

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5.1.1; The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.

² NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-6.5.1.2; Sprinklers shall be arranged to comply with 5-5.5.2, Table 5-6.5.1.2, and Figure 5-6.5.1.2(a).
Exception No. 1: Sprinklers shall be permitted to be spaced on opposite sides of obstructions not exceeding 4 ft (1.2 m) in width provided the distance from the centerline of the obstruction to the sprinklers does not exceed one-half the allowable distance permitted between sprinklers.
Exception No. 2: Obstructions located against the wall and that are not over 30 in. (762 mm) in width shall be permitted to be protected in accordance with Figure 5-6.5.1.2(b).
Distance from Sprinklers to Side of Obstruction (A) Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.) (B)
Less than 1 ft 0
1 ft to less than 1 ft 6 in. 2 1/2
1 ft 6 in. to less than 2 ft 3 1/2
2 ft to less than 2 ft 6 in. 5 1/2
2 ft 6 in. to less than 3 ft 7 1/2
3 ft to less than 3 ft 6 in. 9 1/2
3 ft 6 in. to less than 4 ft 12
4 ft to less than 4 ft 6 in. 14
4 ft 6 in. to less than 5 ft 16 1/2
5 ft and greater 18
For SI units, 1 in. = 25.4 mm; 1 ft = 0.3048 m.
Note: For (A) and (B), refer to Figure 5-6.5.1.2(a).

³ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-6.5.3.1; Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.
Exception: Obstructions that are not fixed in place, such as conference tables.

4 NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-6.3.3 Minimum Distance from Walls.
Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall.

Based on record review and interview, the facility failed to ensure the kitchen hood exhaust system contained inspection access points in accordance with NFPA 96, 1998 Edition, Section 4-3.1. This deficiency could affect 1 of 6 smoke compartments.

Findings include:

During a review of evidence that the kitchen hood fire extinguishing system and all of its components were inspected and maintained semiannually, the reports revealed the kitchen hood was not in compliance.¹

The report described the duct system needed access panels at each change of direction to allow proper photo documentation of the entire duct system. The report was dated 5/17/15.

During an interview on 8/10/15 at 12:15 p.m., staff member A, director of facilities, stated they had contacted the service contractor and were waiting to be scheduled.

There was also a "potential hazard notification," dated 5/12/14, describing this situation.

¹ NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition, Section 4-3.1; Openings shall be provided at the sides or at the top of the duct, whichever is more accessible, and at changes of direction. Openings shall be protected by approved access panels that comply with 4-3.4.4.
Exception: Openings shall not be required in portions of the duct that are accessible from the duct entry or discharge.

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC and NFPA 70, 1999 Edition, Article 110-26 . These deficiencies could affect 4 of 6 smoke compartments.

Findings include:

1. During an observation on 8/11/15 at 8:41 a.m., the radiology break room was inspected. There was a refrigerator and a microwave plugged into a power strip.¹

2. During an observation on 8/11/15 at 8:59 a.m., the ER office was inspected. There was a microwave plugged into a power strip.¹

3. During an observation 8/11/15 at 9:45 a.m., patient room 117 was inspected. There was a rolling cart with a refrigerator and a microwave in the room. The refrigerator and the microwave were plugged into a power strip on the cart. Additionally, the power strip was not United Laboratory (UL) listed 1363.¹

4. During an observation on 8/11/15 at 9:50 a.m., the patient hall mechanical room was inspected. There were sitting chairs and a broom stored in front of the electrical panels in the room. The panels were not readily accessible.²

5. During an observation on 8/11/15 at 10:09 a.m., the business office was inspected. In the patient accounting room, there was a refrigerator plugged into a power strip.¹

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

² NFPA 70, 1999 Edition, Article 110-26 Spaces About Electrical Equipment, Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(a) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of (1), (2), and (3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.
Exception No. 1: Working space shall not be required in back or sides of assemblies, such as dead-front switchboards or motor control centers, where there are no renewable or adjustable parts, such as fuses or switches, on the back or sides and where all connections are accessible from locations other than the back or sides. Where rear access is required to work on de-energized parts on the back of enclosed equipment, a minimum working space of 30 in. (762 mm) horizontally shall be provided.
Exception No. 2: By special permission, smaller spaces shall be permitted where all uninsulated parts are at a voltage no greater than 30 volts rms, 42 volts peak, or 60 volts dc.
Exception No. 3: In existing buildings where electrical equipment is being replaced, Condition 2 working clearance shall be permitted between dead-front switchboards, panelboards, or motor control centers located across the aisle from each other where conditions of maintenance and supervision ensure that written procedures have been adopted to prohibit equipment on both sides of the aisle from being open at the same time and qualified persons who are authorized will service the installation.

Table 110-26(a). Working Spaces

Minimum Clear Distance (ft)
Nominal Voltage to Ground Condition 1 Condition 2 Condition 3
0-150 3 3 3
151-600 3 31/2 4

(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.
(3) Height of Working Space. The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26(e). Within the height requirements of this section, other equipment associated with the electrical installation located above or below the electrical equipment shall be permitted to extend not more than 6 in. (153 mm) beyond the front of the electrical equipment.
(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC. This deficiency could affect 1 of 1 smoke compartment.

Findings include:

During an observation on 8/11/15 at 8:17 a.m., the chemotherapy nurses' station of inspected. There was a refrigerator plugged into a power strip.¹

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

Based on observation, the facility failed to ensure that alcohol-based hand rub (ABHR) dispensers were not installed directly over an ignition source per CMS Survey & Certification Policy S&C-05-33. This deficiency could affect 1 of 6 smoke compartments.

Findings include:

During an observation on 8/11/15 at 10:34 a.m., the south wing conference center was inspected. There was an alcohol-based hand rub dispenser mounted directly over an outlet.¹

¹ CMS interpretations under Survey & Certification (S&C)-05-33 policy issued on June 9, 2005, states ABHR dispensers shall meet the NFPA amendment to the 2000 Life Safety Code regarding the installation of ABHR dispensers in exit corridors and on interior walls. The Certification Bureau enforces that ABHR dispensers be offset by at least one inch and not mounted directly above any electrical source.

Based on observation, the facility failed to maintain the fire resistance rating of 2-hour fire rated walls/barriers in accordance with NFPA 101, 2000 Edition, Section 8.2.3.2.4.2. This deficiency could affect 2 of 6 smoke compartments.

Findings include:

During an observation on 8/12/15 at 8:10 a.m., the two-hour barrier at the north end of the patient wing was inspected. There was an open conduit with wires running through the barrier. The conduit was not sealed on either side of the barrier.¹

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 8.2.3.2.4.2; Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) * Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observation, the facility failed to properly label a convenience exit as "No Exit", as required in NFPA 101, 2000 Edition, Section 7.10.8.1. This deficiency could affect 1 of 6 smoke compartments.

Findings include:

During an observation on 8/11/15 at 10:37 a.m., the south wing conference room was inspected. The door into the courtyard was not a required exit door but could be confused as an exit, as it lead to the outside. The door was not signed as "NO EXIT."¹

¹ NFPA 101, 2000 Edition, Section 7.10.8.1; Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads NO EXIT. Further, such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.

Based on observation, the facility failed to maintain smoke barriers per NFPA 101, 2000 Edition, Section 8.3.6.1. The deficiency could affect 2 of 6 smoke compartments.

Findings include:

During an observation on 8/12/15 at 8:29 a.m., the 1-hour fire/smoke rated wall in the nurses' break room had one unsealed penetration on the east wall of the room.¹

¹ NFPA 101, 2000 Edition, Section 8.3.6.1; Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observations, the facility failed to protect a hazardous area per NFPA 101, 2000 Edition, Section 19.3.2.1, by not securing the doors to the hazardous area with self-closing devices. These deficiencies could affect 1 of 6 smoke compartments.

Findings include:

1. During an observation on 8/11/15 at 9:13 a.m., the obstetrics storage room was inspected. The room is over 50 square feet and had no self-closer on the door.¹

2. During an observation on 8/11/15 at 11:01 a.m., the floor care room was inspected. The room is over 50 square feet, stored combustible items, and there was no self-closer on the door.¹

3. During an observation on 8/11/15 at 2:23 p.m., the outpatient surgery storage room was inspected. It is over 50 square feet, contained combustible storage, and there was no self-closer on the door.¹

¹ NFPA 101, 2000 Edition, Section 19.3.2.1; Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 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 square feet (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 square feet (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have non-rated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Based on observation and interview, the facility failed to provide for a hard surface path from an exit discharge to the public way in accordance with NFPA 101, 2000 Edition, Section 7.7.1. This deficiency had a potential to affect 1 of 6 smoke compartments.

Findings include:

During an observation on 8/11/15 at 10:06 a.m., the exit discharge from the labor and delivery area opened onto a lawn area. No hard surface path lead from this exit discharge continuously to the public way.¹

In an interview on 8/11/15 at 10:06 a.m., staff member A, director of facilities, said the Army Corp of Engineers will not allow any construction of a path near the levy of the Milk River.

The levy was observed to be 15 yards from the exit discharge.

¹ NFPA 101, 2000 Edition, Section 7.7.1; A hard surface path from the exit discharge to the public way shall be provided in climates where weather such as snow or ice or heavy rain may hinder evacuation across lawn or soil surfaces.

Based on record review and interview, the facility failed to conduct load voltage tests on the batteries of the fire alarm control panel (FACP) semi-annually, as required per NFPA 72, 1999 Edition, Table 7-3.2. The deficiency could affect 6 of 6 smoke compartments.

Findings include:

Review of the alarm system test records reflected the annual maintenance of the panel was conducted on 2/23/15, and reflected the load voltage testing had been done on the sealed lead-acid batteries of the panel. There was no documentation of load voltage testing taking place six months prior to the annual test, or up until the time of the survey.¹

During an interview on 8/10/15 at 11:15 a.m., staff member A, director of facilities, stated the load voltage tests were not being done on a semi-annual basis.

¹ NFPA 72 National Fire Alarm Code, 1999 Edition, Table 7.3.2 (6)(d)(3), requires sealed lead-acid type batteries to have a "Load Voltage Test" upon initial installation and then semiannually thereafter.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system per NFPA 13, 1999 Edition, Sections 5.1.1, 5-6.5.1.2, 5-6.3.3. and 5-6.5.3.1 These deficiencies could affect 3 of 6 smoke compartments.

Findings include:

1. During an observation on 8/11/15 at 9:09 a.m., the bathroom in patient room 128 was inspected. The sprinkler head in the bathroom was measured to be three inches from the light fixture. The light fixture was also lower than the deflector of the sprinkler head.¹ ²

2. During an observation on 8/11/15 at 9:56 a.m., the patient hall mechanical room was inspected. There was an air handling duct measure four feet by eight feet with no sprinkler coverage underneath.³

3. During an observation on 8/11/15 at 2:45 p.m., the sterile corridor was inspected. There was a sprinkler head in the middle of the corridor that was up inside the escutcheon ring, the spray of the head would be completely blocked in all directions from the head.¹ ²

4. During an observation on 8/11/15 at 2:45 p.m., a sprinkler head in a storage portion of the sterile corridor was measured to be two inches from the wall.4

In an interview on 8/12/15 at 10:20 a.m., staff member A, director of facilities, said the sprinkler was only about two inches from the wall.

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5.1.1; The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.

² NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-6.5.1.2; Sprinklers shall be arranged to comply with 5-5.5.2, Table 5-6.5.1.2, and Figure 5-6.5.1.2(a).
Exception No. 1: Sprinklers shall be permitted to be spaced on opposite sides of obstructions not exceeding 4 ft (1.2 m) in width provided the distance from the centerline of the obstruction to the sprinklers does not exceed one-half the allowable distance permitted between sprinklers.
Exception No. 2: Obstructions located against the wall and that are not over 30 in. (762 mm) in width shall be permitted to be protected in accordance with Figure 5-6.5.1.2(b).
Distance from Sprinklers to Side of Obstruction (A) Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.) (B)
Less than 1 ft 0
1 ft to less than 1 ft 6 in. 2 1/2
1 ft 6 in. to less than 2 ft 3 1/2
2 ft to less than 2 ft 6 in. 5 1/2
2 ft 6 in. to less than 3 ft 7 1/2
3 ft to less than 3 ft 6 in. 9 1/2
3 ft 6 in. to less than 4 ft 12
4 ft to less than 4 ft 6 in. 14
4 ft 6 in. to less than 5 ft 16 1/2
5 ft and greater 18
For SI units, 1 in. = 25.4 mm; 1 ft = 0.3048 m.
Note: For (A) and (B), refer to Figure 5-6.5.1.2(a).

³ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-6.5.3.1; Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.
Exception: Obstructions that are not fixed in place, such as conference tables.

4 NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-6.3.3 Minimum Distance from Walls.
Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall.

Based on record review and interview, the facility failed to ensure the kitchen hood exhaust system contained inspection access points in accordance with NFPA 96, 1998 Edition, Section 4-3.1. This deficiency could affect 1 of 6 smoke compartments.

Findings include:

During a review of evidence that the kitchen hood fire extinguishing system and all of its components were inspected and maintained semiannually, the reports revealed the kitchen hood was not in compliance.¹

The report described the duct system needed access panels at each change of direction to allow proper photo documentation of the entire duct system. The report was dated 5/17/15.

During an interview on 8/10/15 at 12:15 p.m., staff member A, director of facilities, stated they had contacted the service contractor and were waiting to be scheduled.

There was also a "potential hazard notification," dated 5/12/14, describing this situation.

¹ NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition, Section 4-3.1; Openings shall be provided at the sides or at the top of the duct, whichever is more accessible, and at changes of direction. Openings shall be protected by approved access panels that comply with 4-3.4.4.
Exception: Openings shall not be required in portions of the duct that are accessible from the duct entry or discharge.

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC and NFPA 70, 1999 Edition, Article 110-26 . These deficiencies could affect 4 of 6 smoke compartments.

Findings include:

1. During an observation on 8/11/15 at 8:41 a.m., the radiology break room was inspected. There was a refrigerator and a microwave plugged into a power strip.¹

2. During an observation on 8/11/15 at 8:59 a.m., the ER office was inspected. There was a microwave plugged into a power strip.¹

3. During an observation 8/11/15 at 9:45 a.m., patient room 117 was inspected. There was a rolling cart with a refrigerator and a microwave in the room. The refrigerator and the microwave were plugged into a power strip on the cart. Additionally, the power strip was not United Laboratory (UL) listed 1363.¹

4. During an observation on 8/11/15 at 9:50 a.m., the patient hall mechanical room was inspected. There were sitting chairs and a broom stored in front of the electrical panels in the room. The panels were not readily accessible.²

5. During an observation on 8/11/15 at 10:09 a.m., the business office was inspected. In the patient accounting room, there was a refrigerator plugged into a power strip.¹

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

² NFPA 70, 1999 Edition, Article 110-26 Spaces About Electrical Equipment, Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(a) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of (1), (2), and (3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.
Exception No. 1: Working space shall not be required in back or sides of assemblies, such as dead-front switchboards or motor control centers, where there are no renewable or adjustable parts, such as fuses or switches, on the back or sides and where all connections are accessible from locations other than the back or sides. Where rear access is required to work on de-energized parts on the back of enclosed equipment, a minimum working space of 30 in. (762 mm) horizontally shall be provided.
Exception No. 2: By special permission, smaller spaces shall be permitted where all uninsulated parts are at a voltage no greater than 30 volts rms, 42 volts peak, or 60 volts dc.
Exception No. 3: In existing buildings where electrical equipment is being replaced, Condition 2 working clearance shall be permitted between dead-front switchboards, panelboards, or motor control centers located across the aisle from each other where conditions of maintenance and supervision ensure that written procedures have been adopted to prohibit equipment on both sides of the aisle from being open at the same time and qualified persons who are authorized will service the installation.

Table 110-26(a). Working Spaces

Minimum Clear Distance (ft)
Nominal Voltage to Ground Condition 1 Condition 2 Condition 3
0-150 3 3 3
151-600 3 31/2 4

(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.
(3) Height of Working Space. The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26(e). Within the height requirements of this section, other equipment associated with the electrical installation located above or below the electrical equipment shall be permitted to extend not more than 6 in. (153 mm) beyond the front of the electrical equipment.
(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

Based on observation, the facility failed to maintain the electrical system and/or its components in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC. This deficiency could affect 1 of 1 smoke compartment.

Findings include:

During an observation on 8/11/15 at 8:17 a.m., the chemotherapy nurses' station of inspected. There was a refrigerator plugged into a power strip.¹

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.