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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. 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. 19.3.2.1

The facility failed to ensure hazardous areas in fully sprinklered existing health care occupancies were separated from other spaces by smoke-resisting partitions and self-closing doors.

Observation determined the double corridor doors to the Laundry Room failed to self-close and latch.

Failure to ensure hazardous areas were separated from other spaces by smoke-resisting partitions increases the risk of death or injury due to fire.

The deficiency affected one (1) of numerous hazardous areas in the facility.

Smoke detectors must not be located in a direct airflow nor closer than 3 ft. (1 m) from an air supply diffuser or return air opening. 19.3.4.5.1, 9.6.2.10.1.1, NFPA 72 17.7.4.1.

The facility failed to ensure the smoke detection system was in compliance with NFPA 72, National Fire Alarm and Signaling Code.

Observation determined six (6) smoke detectors throughout the facility were installed within 3 ft. of an air supply diffuser or return air opening.

Failure to install the smoke detection system as required increases the risk of death or injury due to fire.

This deficiency affected six (6) of numerous smoke detectors in the facility. The smoke detection system serves the entire facility.

Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system. Sprinklers in high-temperature zones shall be of the high-temperature classification. 19.3.5.1, 9.7.1.1(1), NFPA 13 8.3.2, 8.3.2.5(1), Table 8.3.2.5(a)(2).

The facility failed to install the automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide adequate coverage for all portions of the building.

Observation determined one (1) sprinkler in the walk-in freezer and one (1) sprinkler in the walk-in cooler located in the Kitchen were of ordinary-temperature classification. The walk-in freezer and walk-in cooler were equipped with an automatic defrosting feature. NFPA 13 requires sprinklers to be intermediate-rated sprinklers in automatic defrosting walk-in freezers and walk-in coolers.

Failure to install and maintain the automatic sprinkler system in accordance with NFPA 13 increases the risk of injury and death due to fire.

The deficiency affected two (2) of numerous sprinklers in the facility. The automatic sprinkler system serves the entire facility.

Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. 19.7.6, 4.6.12, NFPA 25, 13.2.7.1, 13.3.2.1.1

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25.

Record review and interview with staff determined the control valves and the gauges of the automatic sprinkler system had not been inspected monthly.

Failure to inspect, test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

The deficiency affected the complete automatic sprinkler system, which serves the entire facility.

The facility failed to provide emergency procedures for when the automatic sprinkler system is out of service for more than 10 hours in a 24-hour period. 19.3.5.1, 9.7.6, NFPA 25, 15.5.2

Review of records did not indicate the facility had a written Fire Watch and Notification policy for the automatic sprinkler system.

Failure to provide emergency procedures for when the automatic sprinkler system is out of service for more than 10 hours increases the risk of injury and death due to fire.

The deficiency affected one (1) of one (1) automatic sprinkler system, which serves the entire facility.

Fire extinguishers shall be manually inspected when initially placed in service and thereafter either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals. 19.3.5.12, 9.7.4.1, NFPA 10 7.2.1.1, 7.2.1.2

The facility failed to inspect portable fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Observation determined the inspection tags on all portable fire extinguishers in the facility had not been initialed to indicate monthly inspections during April 2017.

Failure to ensure portable fire extinguishers comply with NFPA 10 increases the risk of death or injury due to fire.

The deficiency affected all portable fire extinguishers in the facility.

Corridor walls shall resist the transfer of smoke. 19.3.6.2.1

The facility failed to ensure corridors were separated from use areas by walls constructed to resist the transfer of smoke.

Observation determined:

1) The Wheelchair Storage Alcove in the corridor by the North Clinic Entrance Vestibule did not have a ceiling which left the corridor open to the interstitial space behind the corridor wall.

2) The Wheelchair Storage Alcove in the corridor by the North Hospital Entrance Vestibule did not have a ceiling which left the corridor open to the interstitial space behind the corridor wall.

Failure to separate corridors from other areas increases the risk of death or injury due to fire.

The deficiency affected two (2) of numerous corridor walls in the facility.

Smoke barriers shall be constructed in accordance with Section 8.5 and shall have a minimum one-half hour fire resistance rating. 19.3.7.3

The facility failed to ensure smoke barriers were at least one-half hour fire resistant and smoke resistant.

Observation determined there was a 2" x 2" opening in the center smoke barrier behind the wheelchair storage area.

Failure to maintain smoke barriers as required increases the risk of death or injury due to fire.

The deficiency affected two (2) of four (4) smoke compartments in the facility.

The facility failed to ensure doors in smoke barrier walls were self-closing and resisted the passage of smoke. 19.3.7.6, 19.3.7.8, 19.3.7.9.

Observation determined the north corridor doors in the east smoke barrier failed to self-close to the fully closed position and resist the passage of smoke.

Failure to ensure smoke barrier doors were self-closing and resisted the passage of smoke increases the risk of injury and death from fire.

This deficiency affected two (2) of four (4) smoke compartments.

The facility failed to provide a documented risk assessment of building systems. NFPA 99, 4.2

Review of documentation and interview of staff determined the facility failed to conduct and document a risk assessment of building systems.

Failure to conduct a risk assessment of building systems increases the risk of injury or death due to fire.

This deficiency affected building systems throughout the entire facility.