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Based on observation, the facility failed to ensure corridor doors would remain latched in accordance with NFPA 101, 2000 Edition, Sections 38.3.2.1, 8.4.1.1, and 8.4.1.3. This deficiency affects 1 of 1 smoke compartment.

Findings include:

1. During an observation on 9/13/16 at 12:11 p.m., the elevator equipment room was inspected. The elevator was found to use a hydraulic hoist, which make the room a hazardous area. The door to the room would not close and latch under the power of the self-closer.¹ ² ³

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 38.3.2.1*; Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.

² NFPA 101 Life Safety Code, 2000 Edition, Section 8.4.1.1*; Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

³ NFPA 101 Life Safety Code, 2000 Edition, Section 8.4.1.3; Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

Based on observations, not all penetrations between floors were sealed limiting the transfer of smoke from one smoke compartment to another in accordance with NFPA 101, 2000 Edition, Section 18.3.1.1 and 8.2.5.1. These deficiencies affect one smoke compartment on the main floor, one smoke compartment on the second floor, and the penthouse.

Findings include:

1. During an observation on 9/13/16 at 7:42 a.m., the warehouse receiving area was inspected. There were several pipes leaving the room vertically, through the ceiling which were not sealed around the pipe.¹

2. During an observation on 9/13/16 at 9:56 a.m., the stairwell to the penthouse was inspected. The door at the top, to the penthouse, was held open on a catch. The access door shall be closed when not occupied by staff. ¹ ²

3. During an observation on 9/13/16 at 10:03 a.m., the second floor telecom room was inspected. There were three, 4-inch conduits going through the one hour floor, which were not sealed around the conduits.¹

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 18.3.1.1; Any vertical opening shall be enclosed or protected in accordance with 8.2.5.
Exception No. 1: Unprotected vertical openings in accordance with 8.2.5.8 shall be permitted.
Exception No. 2: Exception No. 1 to 8.2.5.6(1) shall not apply to patient sleeping and treatment rooms.
Exception No. 3: Multilevel patient sleeping areas in psychiatric facilities shall be permitted without enclosure protection between levels, provided that all the following conditions are met:
(a) The entire normally occupied area, including all communicating floor levels, is sufficiently open and unobstructed so that a fire or other dangerous condition in any part shall be obvious to the occupants or supervisory personnel in the area.
(b) Egress capacity is sufficient to provide simultaneously for all the occupants of all communicating levels and areas, with all communicating levels in the same fire area being considered as a single floor area for purposes of determination of required egress capacity.
(c) The height between the highest and lowest finished floor levels shall not exceed 13 ft (4 m); the number of levels shall not be restricted.
Exception No. 4: Unprotected openings in accordance with 8.2.5.5 shall not be permitted.

² NFPA 101, 2000 Edition, Section 8.2.5.1; Every floor that separates stories in a building shall be constructed as a smoke barrier to provide a basic degree of compartmentation. (See 3.3.182 for definition of Smoke Barrier.)
Exception: This requirement shall not apply where otherwise specified by 8.2.5.5, 8.2.5.6, or Chapters 11 through 42.

Based on observation, the facility failed to maintain the fire protection of a stairwell, in accordance with NFPA 101, 2000 Edition, Sections 39.3.1.1 and 8.2.5.2. This deficiency affects all three floors of the building.

Findings include:

1. During an observation on 10/11/16 at 1:52 p.m., the interior stairwell was inspected. The corridor doors to the stairwell on all three floors were unable to latch. There was packing tape holding the latch in on all the doors.¹ ²

¹ NFPA 101, 2000 Edition, Section 39.3.1.1; Any vertical opening shall be enclosed or protected in accordance with 8.2.5.
Exception No. 1: Unenclosed vertical openings in accordance with 8.2.5.8 shall be permitted.
Exception No. 2: Exit access stairs shall be permitted to be unenclosed in two-story single-tenant spaces that are provided with a single exit in accordance with Exception No. 4 to 39.2.4.2.
Exception No. 3: In buildings protected throughout by an approved automatic sprinkler system in accordance with Section 9.7, unprotected vertical openings shall be permitted. This exception shall be permitted only where no unprotected vertical opening serves as any part of any required means of egress and all required exits consist of outside stairs in accordance with 7.2.2, smokeproof enclosures in accordance with 7.2.3, or horizontal exits in accordance with 7.2.4.Floors below the street floor used for storage or other than business occupancy shall have no unprotected openings to business occupancy floors.

² NFPA 101, 2000 Edition, Section 8.2.5.2*: Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.
Exception No. 1: This requirement shall not apply where otherwise specified by 8.2.5.5, 8.2.5.6, 8.2.5.7, or Chapters 11 through 42.
Exception No. 2: This requirement shall not apply to escalators and moving walks protected in accordance with 8.2.5.11.
Exception No. 3*: This requirement shall not apply to expansion or seismic joints designed to prevent the penetration of fire and shown to have a fire resistance rating of not less than the required fire resistance rating of the floor when tested in accordance with ANSI/UL 2079, Test of Fire Resistance of Building Joint Systems.
Exception No. 4: Enclosure shall not be required for pneumatic tube conveyors protected in accordance with 8.2.3.2.4.2.
Exception No. 5: This requirement shall not apply to existing mail chutes where one of the following conditions is met:
(a) The cross-sectional area does not exceed 16 in.2 (103 cm2).
(b) The building is protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.

Based on observation, the facility failed to ensure that access to exits was marked by approved, readily visible signs properly denoting the way to the means of egress in accordance with NFPA 101, 2000 Edition, Section 7.10.1.4. This deficiency affects 1 of 1 smoke compartment.

Findings include:

1. During an observation on 10/11/16 at 2:05 p.m., the northeast exit door was marked as a principle exit. The corridor outside the door was lacking exit signage to the left or to the right and it was confusing as to which way would be the best way to exit the building.¹

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 7.10.1.4; Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.

Based on observation, the facility failed to ensure that access to exits was marked by approved, readily visible signs properly denoting the way to the means of egress in accordance with NFPA 101, 2000 Edition, Section 7.10.1.4. This deficiency affects 1 of 1 smoke compartment.

Findings include:

1. During an observation on 9/13/16 at 1:40 p.m., the second story main corridor was inspected. There was no visible exit signage.¹

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 7.10.1.4; Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.

Based on observation, the facility failed to ensure that access to exits was marked by approved, readily visible signs properly denoting the way to the means of egress in accordance with NFPA 101, 2000 Edition, Section 7.10.1.4. This deficiency affects 1 of 2 main floor smoke compartments.

Findings include:

1. During an observation on 9/13/16 at 8:15 a.m., the hospital hallway was inspected. The following deficiencies were identified:
a.) The exit sign going east was obstructed by the hanging lights in the hall.
b.) Going west there was no exit sign on the hospital side of the double doors.¹

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 7.10.1.4; Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.

Based on observation, the facility failed to maintain the one hour rating of a smoke barrier in accordance with NFPA 101, 2000 Edition, Section 18.3.7.3. This deficiency affects 1 of 2 main floor smoke compartments.

Findings include:

1. During an observation on 9/13/16 at 10:45 a.m., the 1-hour wall above the administration hallway was inspected. There were three, 4-inch conduits running through the wall which were not sealed.¹

¹ NFPA 101, 2000 Edition, Section 18.3.7.3; Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2*: Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems.

Based on observation, the facility failed to properly protect a hazardous area with 1-hour resistant rated walls and a self-closing rated door in accordance with NFPA 101, 2000 Edition, Sections 38.3.2.1, 8.4.1.1, and 8.4.1.3. This deficiency affects 1 of 1 smoke compartment.

Findings include:

1. During an observation on 9/13/16 at 12:11 p.m., the elevator equipment room was inspected. The elevator was found to use a hydraulic hoist, which make the room a hazardous area. The door to the room would not close and latch under the power of the self-closer.¹ ² ³

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 38.3.2.1*; Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.

² NFPA 101 Life Safety Code, 2000 Edition, Section 8.4.1.1*; Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

³ NFPA 101 Life Safety Code, 2000 Edition, Section 8.4.1.3; Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

Based on observations, the facility failed to properly protect a hazardous area with 1-hour resistant rated walls and a self-closing rated door in accordance with NFPA 101, 2000 Edition, Sections 8.4.1.1 and 8.2.3.2.1, and NFPA 80, 1999 Edition, Section 2-1.4.1. These deficiencies affect one smoke compartment on main floor, and one smoke compartment on the second floor.

Findings include:

1. During an observation on 9/13/16 at 8:35 a.m., the Emergency Room (ER) clean hold room was inspected. The room was over 50 square feet and was not latching under the power of the self-closer.¹ ² ³

2. During an observation on 9/13/16 at 8:36 a.m., the ER soiled utility room was inspected. The room was over 50 square feet, and it was not latching under the power of the self-closer.¹ ² ³

3. During an observation on 9/13/16 at 9:17 a.m., the post-anesthetic care unit (PACU) was inspected. The storage room door would not latch under the power of the self-closer.¹ ² ³

¹ NFPA 101, 2000 Edition, Section 8.4.1.1*; Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42

² NFPA 101, 2000 Edition, Section 8.2.3.2.1; Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) * Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

³ NFPA 80 Standard for Fire Doors and Fire Windows, 1999 Edition, Section 2-1.4.1 Self-Closing Doors; Self-closing doors shall swing easily and freely and shall be equipped with a closing device to cause the door to close and latch each time it is opened. The closing mechanism shall not have a hold-open feature.

Based on observation, the facility failed to keep protected stairwells free from use from anything but egress in accordance with NFPA 101, 2000 Edition, Sections 38.2.1.1, 7.1.3.2.3, A.7.1.3.2.3, and 7.2.2.5.3. This deficiency affects 1 of 1 smoke compartment.

Findings include:

1. During an observation on 9/13/16 at 1:37 p.m., the ICC vision stairwell was inspected. There were shredder bins being stored at the bottom of the stairwell.¹ ² ³ 4

¹ NFPA 101, 2000 Edition, Section 38.2.1.1; All means of egress shall be in accordance with Chapter 7 and this chapter.

² NFPA 101, 2000 Edition, Section 7.1.3.2.3*; An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge.

³ NFPA 101, 2000 Edition, Section A.7.1.3.2.3; This provision prohibits the use of exit enclosures for storage or for installation of equipment not necessary for safety. Occupancy is prohibited other than for egress, refuge, and access. The intent is that the exit enclosure essentially be " sterile " with respect to fire safety hazards

4 NFPA 101, 2000 Edition, Section 7.2.2.5.3* Usable Space.; There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.
Exception: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure. (See also 7.1.3.2.3.)

Based on observations, the facility failed to keep protected stairwells free from use from anything but egress in accordance with NFPA 101, 2000 Edition, Sections 7.1.3.2.3, and A.7.1.3.2.3. These deficiencies affect 2 main floor smoke compartments, and 2 second floor smoke compartments.

Findings include:

1. During an observation on 9/12/16 at 4:38 p.m., the emergency room (ER) stairwell was inspected. There were three ER beds being stored under the stairs, along with a cabinet.¹ ²

2. During an observation on 9/12/16 at 4:42 p.m., the main stairwell was inspected. There was also storage of two paper shredder bins, two procedure tables, and two fans, along with some lockers being stored in the stairwell.¹ ²

3. During an observation on 9/12/16 at 4:45 p.m., the east hospital stairwell was inspected. There was maintenance supplies and Christmas decorations being stored in the stairwell.¹ ²

¹ NFPA 101, 2000 Edition, Section 7.1.3.2.3*; An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge.

² NFPA 101, 2000 Edition, Section A.7.1.3.2.3; This provision prohibits the use of exit enclosures for storage or for installation of equipment not necessary for safety. Occupancy is prohibited other than for egress, refuge, and access. The intent is that the exit enclosure essentially be " sterile " with respect to fire safety hazards.

Based on observations, the facility failed to maintain marked exit routes with free and unobstructed egress to full and instant use per NFPA 101, 2000 Edition, Sections, 39.2.2.2.2, 7.1.10.1, and 7.2.1.5.1. These deficiencies affect 1 of 1 smoke compartment.

Findings include:

1. During an observation on 10/11/16 at 1:25 p.m., the exit corridor near the radiology department was inspected. There was furniture placed in the corridor for a patient waiting area. There was also a large potted plant, and a sign presenting newly signed staff hired by the clinic.¹ ²
2. During an observation, the northeast exit door out of the pediatric occupancy was found to be locked with a keyed lock.³ 4

¹ NFPA 101, 2000 Edition, Section 7.1.10.1*; Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. NFPA 101, 2000 Edition, Section 39.2.2.2.2*; Locks complying with Exception No. 2 to 7.2.1.5.1 shall be permitted only on principal entrance/exit doors.

² NFPA 101, 2000 Edition, Section 7.1.10.2.1; No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

³ NFPA 101, 2000 Edition, Section 39.2.2.2.2; Locks complying with Exception No. 2 to 7.2.1.5.1 shall be permitted only on principal entrance/exit doors.

4 NFPA 101, 2000 Edition, Section 7.2.1.5.1; Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
Exception No. 1: This requirement shall not apply where otherwise provided in Chapters 18 through 23.
Exception No. 2: Exterior doors shall be permitted to have key-operated locks from the egress side, provided that the following criteria are met:
(a) Permission to use this exception is provided in Chapters 12 through 42 for the specific occupancy.
(b) On or adjacent to the door, there is a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high on a contrasting background that reads as follows:
THIS DOOR TO REMAIN UNLOCKED
WHEN THE BUILDING IS OCCUPIED
(c) The locking device is of a type that is readily distinguishable as locked.
(d) A key is immediately available to any occupant inside the building when it is locked.
Exception No. 2 shall be permitted to be revoked by the authority having jurisdiction for cause.
Exception No. 3: Where permitted in Chapters 12 through 42, key operation shall be permitted, provided that the key cannot be removed when the door is locked from the side from which egress is to be made.

Based on observation, record review and interview, the facility failed to ensure emergency light 30 second monthly and 90-minute annual tests were conducted in accordance with NFPA 101, 2000 Edition, Section 7.9.3. This deficiency affects all battery backup emergency lights.

Findings include:

1. During an observation on 9/13/16 at 2:54 p.m., battery backup emergency lighting was present in the facility.

During review of facility records for testing emergency lighting, the facility did not have documentation of 30 second monthly and 90 minute annual testing of the emergency lighting.¹

During an interview on 9/13/16 at 2:54 p.m., staff member A stated this was not being done in this clinic.

¹ NFPA 101, 2000 Edition, Section 7.9.3 Periodic Testing of Emergency Lighting Equipment; A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and half hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on observation, the facility failed to maintain the fire alarm control panel and all components in accordance with NFPA 72 National Fire Alarm Code, 1999 Edition, Section 1-5.2.5.2. This deficiency affects 1 of 1 smoke compartment in the facility.

Findings include:

1. During an observation on 9/13/16 at 3:42 p.m., the breaker panel and breaker for the fire alarm control panel was not identified, in red, as the breaker that controlled the circuit to the panel.¹

¹ NFPA 72 National Fire Alarm Code, 1999 Edition, Section 1-5.2.5.2; Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Based on observation, the facility failed to maintain the fire alarm control panel and all components in accordance with NFPA 72 National Fire Alarm Code, 1999 Edition, Section 1-5.2.5.2. This deficiency affects 1 of 1 smoke compartment.

Findings include:

1. During an observation on 9/13/16 at 1:59 p.m., the breaker at the panel identifying which breaker goes to the fire alarm control panel was not labeled properly.¹

¹ NFPA 72 National Fire Alarm Code, 1999 Edition, Section 1-5.2.5.2; Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

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 affects 1 of 1 smoke compartment.

Findings include:

1. Review of facility fire alarm records failed to reflect a semiannual voltage test was performed.

In an interview on 9/13/16 at 8:00 a.m., staff member A stated there would be no semi-annual voltage test.

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 semi-annually thereafter.

Based on record review, the facility failed to document all parts of the fire alarm system were tested annually, as required per NFPA 72, 1999 Edition, Table 7-3.2. The deficiency affects 1 of 1 smoke compartments.

Findings include:

1. A record review of the facility fire alarm documentation reflected the enunciating devices, horns and strobes, as well as the manual pull stations were not documented as having been tested during the last annual fire alarm inspection.¹

¹ NFPA 72 National Fire Alarm Code, 1999 Edition, Section 7-3.2* Testing; Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.
Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.

Based on observation, the facility failed to maintain the automatic sprinkler system per NFPA 13, 1999 Edition, Section 5-15.4.2. The deficiency affects two main floor smoke compartments, and two second story smoke compartments.

Findings include:

1. During an observation on 9/13/16 at 7:47 a.m., the inspector's test for the sprinkler system was identified as leading into the main drain which flowed out of a two-inch pipe.¹ An alarm test connection not less than 1 in. (25.4 mm) in diameter, terminating 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.

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-15.4.2* Wet Pipe Systems; An alarm test connection not less than 1 in. (25.4 mm) in diameter, terminating 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, shall be provided to test each waterflow alarm device for each system. The test connection valve shall be readily accessible. The discharge shall be to the outside, to a drain connection capable of accepting full flow under system pressure, or to another location where water damage will not result.

Based on observation, the facility failed to maintain the automatic sprinkler system per NFPA 13, 1999 Edition, Section 5-1.1. This deficiency affects 1 of 2 main floor smoke compartments.

Findings include:

1. During an observation on 9/12/16 at 4:27 p.m., operating room #3 was inspected. There was a sprinkler head in the room missing the escutcheon ring.

¹ NFPA 13, 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.

Based on observation, the facility failed to maintain the automatic sprinkler system per NFPA 25, 1998 Edition, Section 2-2.1.1. This deficiency affects 1 of 1 smoke compartment.

Findings include:

1. During an observation on 9/13/16 at 2:54 p.m., the sprinkler head in the bathroom was found to be totally covered in dust and foreign materials.¹

¹ NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition, Section 2-2.1.1*; Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1*: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Based on observations, the facility failed to maintain the automatic sprinkler system per NFPA 13, 1999 Edition, Sections 3-2.9.1, 5-1.1, & 5-6.5.1.2 and NFPA 25, 1998 Edition, Section 2-2.1.3. These deficiencies affects 1 of 1 smoke compartment.

Findings include:

1. During an observation on 9/13/16 at 12:29 p.m., the infusion registration area was inspected. There was a sprinkler head missing the escutcheon ring.¹

2. During an observation on 9/13/16 at 12:32 p.m., the Clinical Trials Pharmacy area was inspected. There was a sprinkler head missing the escutcheon ring.¹

3. During an observation on 9/13/16 at 12:38 p.m., the receiving/housekeeping closet was found to be missing a ceiling tile.¹

4. During an observation on 9/13/16 at 12:54 p.m., the standpipe in the center west portion of the building was inspected. The following deficiencies were found:
a.) There was only three spare sprinkler heads in the box next to the standpipe.² ³
b.) There was no wrench with the heads.³

5. During an observation on 9/13/16 at 1:03 p.m., the elevator room, first floor, center, was inspected. The following deficiencies were found:
a.) The ceiling was open.¹
b.) The sprinkler head in the room was missing an escutcheon ring.¹

6. During an observation on 9/13/16 at 1:08 p.m., the ICC dressing room was inspected. The sprinkler head was missing the escutcheon ring.¹

7. During an observation on 9/13/16 at 1:31 p.m., the second floor start room 2 was inspected. The sprinkler head was missing the escutcheon ring.¹

8. During an observation on 9/13/16 at 1:56 p.m., the urology storage room was inspected. There was no escutcheon ring on the sprinkler head.¹

9. During an observation on 9/13/16 at 2:08 p.m., the specialty procedures soiled utility storage room was inspected. The sprinkler head was found to be blocked by the light fixture in the room.4

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, 1999 Edition, Section, 3-2.9.1; A supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced. These sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property. The sprinklers shall be kept in a cabinet located where the temperature to which they are subjected will at no time exceed 100°F (38°C).

³ NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition, Section 2-2.1.3; The supply of spare sprinklers shall be inspected annually for the following:
(a) The proper number and type of sprinklers
(b) A sprinkler wrench for each type of sprinkler

4 NFPA 13, 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).
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP)
Distance from Sprinklers to Maximum Allowable Distance of
Side of Obstruction (A) 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).

Based on observation, the facility failed to maintain travel distances for portable fire extinguishers per NFPA 10, 1998 Edition, Sections 3-1.4 and 3-2.1. This deficiency affects 1 of 1 smoke compartment.

Findings include:

1. During an observation on 10/11/16 at 1:45 p.m., the distance traveled in the corridor around the X-ray occupancy from the main entry on the level to the nearest portable fire extinguisher was measured to be approximately 228 feet. There was one fire extinguisher inside the locked x-ray occupancy, which is not being used for other than a back-up to the main hospital x-ray system.¹ ²

¹ NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 3-1.4; On each floor level, the area protected and the travel distances shall be based on fire extinguishers installed in accordance with Table 3-2.1 and Table 3-3.1.

² NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 3-2 Fire Extinguisher Size and Placement for Class A Hazards.
3-2.1
Minimal sizes of fire extinguishers for the listed grades of hazards shall be provided on the basis of Table 3-2.1, except as modified by 3-2.2. Fire extinguishers shall be located so that the maximum travel distances shall not exceed those specified in Table 3-2.1, except as modified by 3-2.2. (See Appendix E.)
Table 3-2.1 Fire Extinguisher Size and Placement for Class A Hazards

Light (Low) Hazard Occupancy
Minimum rated single extinguisher 2-A +
Maximum floor area per unit of A 3000 ft2
Maximum floor area for extinguisher 11,250 ft2 **
Maximum travel distance to extinguisher 75 ft
For SI units: 1 ft = 0.305 m; 1 ft2 = 0.0929 m2
* Two 21/2-gal (9.46-L) water-type extinguishers can be used to fulfill the requirements of one 4-A rated extinguisher.
** See E-3.3.
+ Up to two water-type extinguishers, each with 1-A rating, can be used to fulfill the requirements of one 2-A rated extinguisher.

Based on observation, the facility failed to timely inspect fire extinguishers in accordance with NFPA 10, 1998 Edition, Sections 4-3.4.2 and 4-4.4. This deficiency affects all fire extinguishers on first and second floor.

Findings include:

1. During an observation on 9/12/16 at 4:15 p.m., a portable extinguisher was inspected. It had a yellow inspection tag with months of the year punched out. There were no initials identifying who did the monthly inspections, nor who did the annual inspections of the extinguishers. This was indicative of all the extinguishers in the facility. There were several extinguishers which also did not have each month punched out on the tag for monthly inspections.¹ ²

¹ NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 4-3.4.2; At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

² NFPA 10 , 1998 Edition, Section, 4-4.4* Maintenance Recordkeeping; Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.

Based on observations, the facility failed to timely inspect fire extinguishers in accordance with NFPA 10, 1998 Edition, Sections 4-3.4.2 and 4-4.4. This deficiency affects 1 of 1 smoke compartment.

Findings include:

1. During an observation on 9/13/16 at 12:05 p.m., the Immediate Care Center (ICC) was inspected. The portable fire extinguisher was found to have a label that did not include the initials of the person doing the monthly inspection nor the identification of the person who did the annual service.¹ ²

¹ NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 4-3.4.2; At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

² NFPA 10, 1998 Edition, Section, 4-4.4* Maintenance Recordkeeping; Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.

Based on observation, the facility failed to store oxygen cylinders in accordance with the standards of NFPA 99, 1999 Edition, Section 4-3.5.2.1. This deficiency affects 1 of 1 second floor smoke compartment.

Findings include:

During an observation on 9/13/16 at 12:42 p.m., respiratory therapy was inspected. There was a K-sized tank free standing in the room.¹

¹ NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 4-3.5.2.1; Gases in Cylinders and Liquefied Gases in Containers - Level 1, (a) Handling of Gases; requires administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility. (b)Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed: 27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Based on observation, the facility failed to store oxygen cylinders in accordance with the standards of NFPA 99, 1999 Edition, Section 4-3.5.2.1. This deficiency affects one smoke compartment on the main floor.

Findings include:

1. During an observation on 9/13/16 at 8:33 a.m., the ER restroom was was inspected. There was an E-sized oxygen tank free-standing in the room.¹

¹ NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 4-3.5.2.1; Gases in Cylinders and Liquefied Gases in Containers - Level 1, (a) Handling of Gases; requires administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility. (b)Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed: 27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

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

Findings include:

1. During an observation on 9/13/16 at 3:30 p.m., the vaccine refrigerator was inspected. It was found to be plugged into the power strip in the room.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 observations and interview, the facility failed to maintain the electrical system and/or its components in accordance with NFPA 70, 1999 Edition, Article 110-26. This deficiency affects 1 of 1 smoke compartment.

Findings include:

During an observation on 9/13/16 at 2:56 p.m., the room in the back of the facility where the breaker panels were housed was inspected. The panels were found to be blocked by empty boxes and garbage cans.¹

¹ 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 3 1/2 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 observations, 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. These deficiencies affect 1 of 2 main floor smoke compartments and 1 of 2 second floor smoke compartments.

Findings include:

1. During an observation on 9/12/16 at 4:29 p.m., the PACU was inspected. There were two ABHR dispensers mounted over outlets in the room.¹

2. During an observation on 9/13/16 at 8:22 a.m., the ER waiting room was inspected. There was an ABHR dispenser installed over an outlet.¹

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

Based on observation, the facility failed to ensure corridor doors would remain latched in accordance with NFPA 101, 2000 Edition, Sections 38.3.2.1, 8.4.1.1, and 8.4.1.3. This deficiency affects 1 of 1 smoke compartment.

Findings include:

1. During an observation on 9/13/16 at 12:11 p.m., the elevator equipment room was inspected. The elevator was found to use a hydraulic hoist, which make the room a hazardous area. The door to the room would not close and latch under the power of the self-closer.¹ ² ³

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 38.3.2.1*; Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.

² NFPA 101 Life Safety Code, 2000 Edition, Section 8.4.1.1*; Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

³ NFPA 101 Life Safety Code, 2000 Edition, Section 8.4.1.3; Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

Based on observations, not all penetrations between floors were sealed limiting the transfer of smoke from one smoke compartment to another in accordance with NFPA 101, 2000 Edition, Section 18.3.1.1 and 8.2.5.1. These deficiencies affect one smoke compartment on the main floor, one smoke compartment on the second floor, and the penthouse.

Findings include:

1. During an observation on 9/13/16 at 7:42 a.m., the warehouse receiving area was inspected. There were several pipes leaving the room vertically, through the ceiling which were not sealed around the pipe.¹

2. During an observation on 9/13/16 at 9:56 a.m., the stairwell to the penthouse was inspected. The door at the top, to the penthouse, was held open on a catch. The access door shall be closed when not occupied by staff. ¹ ²

3. During an observation on 9/13/16 at 10:03 a.m., the second floor telecom room was inspected. There were three, 4-inch conduits going through the one hour floor, which were not sealed around the conduits.¹

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 18.3.1.1; Any vertical opening shall be enclosed or protected in accordance with 8.2.5.
Exception No. 1: Unprotected vertical openings in accordance with 8.2.5.8 shall be permitted.
Exception No. 2: Exception No. 1 to 8.2.5.6(1) shall not apply to patient sleeping and treatment rooms.
Exception No. 3: Multilevel patient sleeping areas in psychiatric facilities shall be permitted without enclosure protection between levels, provided that all the following conditions are met:
(a) The entire normally occupied area, including all communicating floor levels, is sufficiently open and unobstructed so that a fire or other dangerous condition in any part shall be obvious to the occupants or supervisory personnel in the area.
(b) Egress capacity is sufficient to provide simultaneously for all the occupants of all communicating levels and areas, with all communicating levels in the same fire area being considered as a single floor area for purposes of determination of required egress capacity.
(c) The height between the highest and lowest finished floor levels shall not exceed 13 ft (4 m); the number of levels shall not be restricted.
Exception No. 4: Unprotected openings in accordance with 8.2.5.5 shall not be permitted.

² NFPA 101, 2000 Edition, Section 8.2.5.1; Every floor that separates stories in a building shall be constructed as a smoke barrier to provide a basic degree of compartmentation. (See 3.3.182 for definition of Smoke Barrier.)
Exception: This requirement shall not apply where otherwise specified by 8.2.5.5, 8.2.5.6, or Chapters 11 through 42.

Based on observation, the facility failed to maintain the fire protection of a stairwell, in accordance with NFPA 101, 2000 Edition, Sections 39.3.1.1 and 8.2.5.2. This deficiency affects all three floors of the building.

Findings include:

1. During an observation on 10/11/16 at 1:52 p.m., the interior stairwell was inspected. The corridor doors to the stairwell on all three floors were unable to latch. There was packing tape holding the latch in on all the doors.¹ ²

¹ NFPA 101, 2000 Edition, Section 39.3.1.1; Any vertical opening shall be enclosed or protected in accordance with 8.2.5.
Exception No. 1: Unenclosed vertical openings in accordance with 8.2.5.8 shall be permitted.
Exception No. 2: Exit access stairs shall be permitted to be unenclosed in two-story single-tenant spaces that are provided with a single exit in accordance with Exception No. 4 to 39.2.4.2.
Exception No. 3: In buildings protected throughout by an approved automatic sprinkler system in accordance with Section 9.7, unprotected vertical openings shall be permitted. This exception shall be permitted only where no unprotected vertical opening serves as any part of any required means of egress and all required exits consist of outside stairs in accordance with 7.2.2, smokeproof enclosures in accordance with 7.2.3, or horizontal exits in accordance with 7.2.4.Floors below the street floor used for storage or other than business occupancy shall have no unprotected openings to business occupancy floors.

² NFPA 101, 2000 Edition, Section 8.2.5.2*: Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.
Exception No. 1: This requirement shall not apply where otherwise specified by 8.2.5.5, 8.2.5.6, 8.2.5.7, or Chapters 11 through 42.
Exception No. 2: This requirement shall not apply to escalators and moving walks protected in accordance with 8.2.5.11.
Exception No. 3*: This requirement shall not apply to expansion or seismic joints designed to prevent the penetration of fire and shown to have a fire resistance rating of not less than the required fire resistance rating of the floor when tested in accordance with ANSI/UL 2079, Test of Fire Resistance of Building Joint Systems.
Exception No. 4: Enclosure shall not be required for pneumatic tube conveyors protected in accordance with 8.2.3.2.4.2.
Exception No. 5: This requirement shall not apply to existing mail chutes where one of the following conditions is met:
(a) The cross-sectional area does not exceed 16 in.2 (103 cm2).
(b) The building is protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.

Based on observation, the facility failed to ensure that access to exits was marked by approved, readily visible signs properly denoting the way to the means of egress in accordance with NFPA 101, 2000 Edition, Section 7.10.1.4. This deficiency affects 1 of 1 smoke compartment.

Findings include:

1. During an observation on 10/11/16 at 2:05 p.m., the northeast exit door was marked as a principle exit. The corridor outside the door was lacking exit signage to the left or to the right and it was confusing as to which way would be the best way to exit the building.¹

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 7.10.1.4; Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.

Based on observation, the facility failed to ensure that access to exits was marked by approved, readily visible signs properly denoting the way to the means of egress in accordance with NFPA 101, 2000 Edition, Section 7.10.1.4. This deficiency affects 1 of 1 smoke compartment.

Findings include:

1. During an observation on 9/13/16 at 1:40 p.m., the second story main corridor was inspected. There was no visible exit signage.¹

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 7.10.1.4; Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.

Based on observation, the facility failed to ensure that access to exits was marked by approved, readily visible signs properly denoting the way to the means of egress in accordance with NFPA 101, 2000 Edition, Section 7.10.1.4. This deficiency affects 1 of 2 main floor smoke compartments.

Findings include:

1. During an observation on 9/13/16 at 8:15 a.m., the hospital hallway was inspected. The following deficiencies were identified:
a.) The exit sign going east was obstructed by the hanging lights in the hall.
b.) Going west there was no exit sign on the hospital side of the double doors.¹

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 7.10.1.4; Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.

Based on observation, the facility failed to maintain the one hour rating of a smoke barrier in accordance with NFPA 101, 2000 Edition, Section 18.3.7.3. This deficiency affects 1 of 2 main floor smoke compartments.

Findings include:

1. During an observation on 9/13/16 at 10:45 a.m., the 1-hour wall above the administration hallway was inspected. There were three, 4-inch conduits running through the wall which were not sealed.¹

¹ NFPA 101, 2000 Edition, Section 18.3.7.3; Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1 hour.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2*: Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems.

Based on observation, the facility failed to properly protect a hazardous area with 1-hour resistant rated walls and a self-closing rated door in accordance with NFPA 101, 2000 Edition, Sections 38.3.2.1, 8.4.1.1, and 8.4.1.3. This deficiency affects 1 of 1 smoke compartment.

Findings include:

1. During an observation on 9/13/16 at 12:11 p.m., the elevator equipment room was inspected. The elevator was found to use a hydraulic hoist, which make the room a hazardous area. The door to the room would not close and latch under the power of the self-closer.¹ ² ³

¹ NFPA 101 Life Safety Code, 2000 Edition, Section 38.3.2.1*; Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.

² NFPA 101 Life Safety Code, 2000 Edition, Section 8.4.1.1*; Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

³ NFPA 101 Life Safety Code, 2000 Edition, Section 8.4.1.3; Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

Based on observations, the facility failed to properly protect a hazardous area with 1-hour resistant rated walls and a self-closing rated door in accordance with NFPA 101, 2000 Edition, Sections 8.4.1.1 and 8.2.3.2.1, and NFPA 80, 1999 Edition, Section 2-1.4.1. These deficiencies affect one smoke compartment on main floor, and one smoke compartment on the second floor.

Findings include:

1. During an observation on 9/13/16 at 8:35 a.m., the Emergency Room (ER) clean hold room was inspected. The room was over 50 square feet and was not latching under the power of the self-closer.¹ ² ³

2. During an observation on 9/13/16 at 8:36 a.m., the ER soiled utility room was inspected. The room was over 50 square feet, and it was not latching under the power of the self-closer.¹ ² ³

3. During an observation on 9/13/16 at 9:17 a.m., the post-anesthetic care unit (PACU) was inspected. The storage room door would not latch under the power of the self-closer.¹ ² ³

¹ NFPA 101, 2000 Edition, Section 8.4.1.1*; Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42

² NFPA 101, 2000 Edition, Section 8.2.3.2.1; Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) * Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

³ NFPA 80 Standard for Fire Doors and Fire Windows, 1999 Edition, Section 2-1.4.1 Self-Closing Doors; Self-closing doors shall swing easily and freely and shall be equipped with a closing device to cause the door to close and latch each time it is opened. The closing mechanism shall not have a hold-open feature.

Based on observation, the facility failed to keep protected stairwells free from use from anything but egress in accordance with NFPA 101, 2000 Edition, Sections 38.2.1.1, 7.1.3.2.3, A.7.1.3.2.3, and 7.2.2.5.3. This deficiency affects 1 of 1 smoke compartment.

Findings include:

1. During an observation on 9/13/16 at 1:37 p.m., the ICC vision stairwell was inspected. There were shredder bins being stored at the bottom of the stairwell.¹ ² ³ 4

¹ NFPA 101, 2000 Edition, Section 38.2.1.1; All means of egress shall be in accordance with Chapter 7 and this chapter.

² NFPA 101, 2000 Edition, Section 7.1.3.2.3*; An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge.

³ NFPA 101, 2000 Edition, Section A.7.1.3.2.3; This provision prohibits the use of exit enclosures for storage or for installation of equipment not necessary for safety. Occupancy is prohibited other than for egress, refuge, and access. The intent is that the exit enclosure essentially be " sterile " with respect to fire safety hazards

4 NFPA 101, 2000 Edition, Section 7.2.2.5.3* Usable Space.; There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.
Exception: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure. (See also 7.1.3.2.3.)

Based on observations, the facility failed to keep protected stairwells free from use from anything but egress in accordance with NFPA 101, 2000 Edition, Sections 7.1.3.2.3, and A.7.1.3.2.3. These deficiencies affect 2 main floor smoke compartments, and 2 second floor smoke compartments.

Findings include:

1. During an observation on 9/12/16 at 4:38 p.m., the emergency room (ER) stairwell was inspected. There were three ER beds being stored under the stairs, along with a cabinet.¹ ²

2. During an observation on 9/12/16 at 4:42 p.m., the main stairwell was inspected. There was also storage of two paper shredder bins, two procedure tables, and two fans, along with some lockers being stored in the stairwell.¹ ²

3. During an observation on 9/12/16 at 4:45 p.m., the east hospital stairwell was inspected. There was maintenance supplies and Christmas decorations being stored in the stairwell.¹ ²

¹ NFPA 101, 2000 Edition, Section 7.1.3.2.3*; An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge.

² NFPA 101, 2000 Edition, Section A.7.1.3.2.3; This provision prohibits the use of exit enclosures for storage or for installation of equipment not necessary for safety. Occupancy is prohibited other than for egress, refuge, and access. The intent is that the exit enclosure essentially be " sterile " with respect to fire safety hazards.

Based on observations, the facility failed to maintain marked exit routes with free and unobstructed egress to full and instant use per NFPA 101, 2000 Edition, Sections, 39.2.2.2.2, 7.1.10.1, and 7.2.1.5.1. These deficiencies affect 1 of 1 smoke compartment.

Findings include:

1. During an observation on 10/11/16 at 1:25 p.m., the exit corridor near the radiology department was inspected. There was furniture placed in the corridor for a patient waiting area. There was also a large potted plant, and a sign presenting newly signed staff hired by the clinic.¹ ²
2. During an observation, the northeast exit door out of the pediatric occupancy was found to be locked with a keyed lock.³ 4

¹ NFPA 101, 2000 Edition, Section 7.1.10.1*; Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. NFPA 101, 2000 Edition, Section 39.2.2.2.2*; Locks complying with Exception No. 2 to 7.2.1.5.1 shall be permitted only on principal entrance/exit doors.

² NFPA 101, 2000 Edition, Section 7.1.10.2.1; No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

³ NFPA 101, 2000 Edition, Section 39.2.2.2.2; Locks complying with Exception No. 2 to 7.2.1.5.1 shall be permitted only on principal entrance/exit doors.

4 NFPA 101, 2000 Edition, Section 7.2.1.5.1; Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
Exception No. 1: This requirement shall not apply where otherwise provided in Chapters 18 through 23.
Exception No. 2: Exterior doors shall be permitted to have key-operated locks from the egress side, provided that the following criteria are met:
(a) Permission to use this exception is provided in Chapters 12 through 42 for the specific occupancy.
(b) On or adjacent to the door, there is a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high on a contrasting background that reads as follows:
THIS DOOR TO REMAIN UNLOCKED
WHEN THE BUILDING IS OCCUPIED
(c) The locking device is of a type that is readily distinguishable as locked.
(d) A key is immediately available to any occupant inside the building when it is locked.
Exception No. 2 shall be permitted to be revoked by the authority having jurisdiction for cause.
Exception No. 3: Where permitted in Chapters 12 through 42, key operation shall be permitted, provided that the key cannot be removed when the door is locked from the side from which egress is to be made.

Based on observation, record review and interview, the facility failed to ensure emergency light 30 second monthly and 90-minute annual tests were conducted in accordance with NFPA 101, 2000 Edition, Section 7.9.3. This deficiency affects all battery backup emergency lights.

Findings include:

1. During an observation on 9/13/16 at 2:54 p.m., battery backup emergency lighting was present in the facility.

During review of facility records for testing emergency lighting, the facility did not have documentation of 30 second monthly and 90 minute annual testing of the emergency lighting.¹

During an interview on 9/13/16 at 2:54 p.m., staff member A stated this was not being done in this clinic.

¹ NFPA 101, 2000 Edition, Section 7.9.3 Periodic Testing of Emergency Lighting Equipment; A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than one and half hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on observation, the facility failed to maintain the fire alarm control panel and all components in accordance with NFPA 72 National Fire Alarm Code, 1999 Edition, Section 1-5.2.5.2. This deficiency affects 1 of 1 smoke compartment in the facility.

Findings include:

1. During an observation on 9/13/16 at 3:42 p.m., the breaker panel and breaker for the fire alarm control panel was not identified, in red, as the breaker that controlled the circuit to the panel.¹

¹ NFPA 72 National Fire Alarm Code, 1999 Edition, Section 1-5.2.5.2; Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Based on observation, the facility failed to maintain the fire alarm control panel and all components in accordance with NFPA 72 National Fire Alarm Code, 1999 Edition, Section 1-5.2.5.2. This deficiency affects 1 of 1 smoke compartment.

Findings include:

1. During an observation on 9/13/16 at 1:59 p.m., the breaker at the panel identifying which breaker goes to the fire alarm control panel was not labeled properly.¹

¹ NFPA 72 National Fire Alarm Code, 1999 Edition, Section 1-5.2.5.2; Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

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 affects 1 of 1 smoke compartment.

Findings include:

1. Review of facility fire alarm records failed to reflect a semiannual voltage test was performed.

In an interview on 9/13/16 at 8:00 a.m., staff member A stated there would be no semi-annual voltage test.

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 semi-annually thereafter.

Based on record review, the facility failed to document all parts of the fire alarm system were tested annually, as required per NFPA 72, 1999 Edition, Table 7-3.2. The deficiency affects 1 of 1 smoke compartments.

Findings include:

1. A record review of the facility fire alarm documentation reflected the enunciating devices, horns and strobes, as well as the manual pull stations were not documented as having been tested during the last annual fire alarm inspection.¹

¹ NFPA 72 National Fire Alarm Code, 1999 Edition, Section 7-3.2* Testing; Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.
Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.

Based on observation, the facility failed to maintain the automatic sprinkler system per NFPA 13, 1999 Edition, Section 5-15.4.2. The deficiency affects two main floor smoke compartments, and two second story smoke compartments.

Findings include:

1. During an observation on 9/13/16 at 7:47 a.m., the inspector's test for the sprinkler system was identified as leading into the main drain which flowed out of a two-inch pipe.¹ An alarm test connection not less than 1 in. (25.4 mm) in diameter, terminating 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.

¹ NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-15.4.2* Wet Pipe Systems; An alarm test connection not less than 1 in. (25.4 mm) in diameter, terminating 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, shall be provided to test each waterflow alarm device for each system. The test connection valve shall be readily accessible. The discharge shall be to the outside, to a drain connection capable of accepting full flow under system pressure, or to another location where water damage will not result.

Based on observation, the facility failed to maintain the automatic sprinkler system per NFPA 13, 1999 Edition, Section 5-1.1. This deficiency affects 1 of 2 main floor smoke compartments.

Findings include:

1. During an observation on 9/12/16 at 4:27 p.m., operating room #3 was inspected. There was a sprinkler head in the room missing the escutcheon ring.

¹ NFPA 13, 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.

Based on observation, the facility failed to maintain the automatic sprinkler system per NFPA 25, 1998 Edition, Section 2-2.1.1. This deficiency affects 1 of 1 smoke compartment.

Findings include:

1. During an observation on 9/13/16 at 2:54 p.m., the sprinkler head in the bathroom was found to be totally covered in dust and foreign materials.¹

¹ NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition, Section 2-2.1.1*; Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1*: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Based on observations, the facility failed to maintain the automatic sprinkler system per NFPA 13, 1999 Edition, Sections 3-2.9.1, 5-1.1, & 5-6.5.1.2 and NFPA 25, 1998 Edition, Section 2-2.1.3. These deficiencies affects 1 of 1 smoke compartment.

Findings include:

1. During an observation on 9/13/16 at 12:29 p.m., the infusion registration area was inspected. There was a sprinkler head missing the escutcheon ring.¹

2. During an observation on 9/13/16 at 12:32 p.m., the Clinical Trials Pharmacy area was inspected. There was a sprinkler head missing the escutcheon ring.¹

3. During an observation on 9/13/16 at 12:38 p.m., the receiving/housekeeping closet was found to be missing a ceiling tile.¹

4. During an observation on 9/13/16 at 12:54 p.m., the standpipe in the center west portion of the building was inspected. The following deficiencies were found:
a.) There was only three spare sprinkler heads in the box next to the standpipe.² ³
b.) There was no wrench with the heads.³

5. During an observation on 9/13/16 at 1:03 p.m., the elevator room, first floor, center, was inspected. The following deficiencies were found:
a.) The ceiling was open.¹
b.) The sprinkler head in the room was missing an escutcheon ring.¹

6. During an observation on 9/13/16 at 1:08 p.m., the ICC dressing room was inspected. The sprinkler head was missing the escutcheon ring.¹

7. During an observation on 9/13/16 at 1:31 p.m., the second floor start room 2 was inspected. The sprinkler head was missing the escutcheon ring.¹

8. During an observation on 9/13/16 at 1:56 p.m., the urology storage room was inspected. There was no escutcheon ring on the sprinkler head.¹

9. During an observation on 9/13/16 at 2:08 p.m., the specialty procedures soiled utility storage room was inspected. The sprinkler head was found to be blocked by the light fixture in the room.4

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, 1999 Edition, Section, 3-2.9.1; A supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced. These sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property. The sprinklers shall be kept in a cabinet located where the temperature to which they are subjected will at no time exceed 100°F (38°C).

³ NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition, Section 2-2.1.3; The supply of spare sprinklers shall be inspected annually for the following:
(a) The proper number and type of sprinklers
(b) A sprinkler wrench for each type of sprinkler

4 NFPA 13, 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).
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP)
Distance from Sprinklers to Maximum Allowable Distance of
Side of Obstruction (A) 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).

Based on observation, the facility failed to maintain travel distances for portable fire extinguishers per NFPA 10, 1998 Edition, Sections 3-1.4 and 3-2.1. This deficiency affects 1 of 1 smoke compartment.

Findings include:

1. During an observation on 10/11/16 at 1:45 p.m., the distance traveled in the corridor around the X-ray occupancy from the main entry on the level to the nearest portable fire extinguisher was measured to be approximately 228 feet. There was one fire extinguisher inside the locked x-ray occupancy, which is not being used for other than a back-up to the main hospital x-ray system.¹ ²

¹ NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 3-1.4; On each floor level, the area protected and the travel distances shall be based on fire extinguishers installed in accordance with Table 3-2.1 and Table 3-3.1.

² NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 3-2 Fire Extinguisher Size and Placement for Class A Hazards.
3-2.1
Minimal sizes of fire extinguishers for the listed grades of hazards shall be provided on the basis of Table 3-2.1, except as modified by 3-2.2. Fire extinguishers shall be located so that the maximum travel distances shall not exceed those specified in Table 3-2.1, except as modified by 3-2.2. (See Appendix E.)
Table 3-2.1 Fire Extinguisher Size and Placement for Class A Hazards

Light (Low) Hazard Occupancy
Minimum rated single extinguisher 2-A +
Maximum floor area per unit of A 3000 ft2
Maximum floor area for extinguisher 11,250 ft2 **
Maximum travel distance to extinguisher 75 ft
For SI units: 1 ft = 0.305 m; 1 ft2 = 0.0929 m2
* Two 21/2-gal (9.46-L) water-type extinguishers can be used to fulfill the requirements of one 4-A rated extinguisher.
** See E-3.3.
+ Up to two water-type extinguishers, each with 1-A rating, can be used to fulfill the requirements of one 2-A rated extinguisher.

Based on observation, the facility failed to timely inspect fire extinguishers in accordance with NFPA 10, 1998 Edition, Sections 4-3.4.2 and 4-4.4. This deficiency affects all fire extinguishers on first and second floor.

Findings include:

1. During an observation on 9/12/16 at 4:15 p.m., a portable extinguisher was inspected. It had a yellow inspection tag with months of the year punched out. There were no initials identifying who did the monthly inspections, nor who did the annual inspections of the extinguishers. This was indicative of all the extinguishers in the facility. There were several extinguishers which also did not have each month punched out on the tag for monthly inspections.¹ ²

¹ NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 4-3.4.2; At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

² NFPA 10 , 1998 Edition, Section, 4-4.4* Maintenance Recordkeeping; Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.

Based on observations, the facility failed to timely inspect fire extinguishers in accordance with NFPA 10, 1998 Edition, Sections 4-3.4.2 and 4-4.4. This deficiency affects 1 of 1 smoke compartment.

Findings include:

1. During an observation on 9/13/16 at 12:05 p.m., the Immediate Care Center (ICC) was inspected. The portable fire extinguisher was found to have a label that did not include the initials of the person doing the monthly inspection nor the identification of the person who did the annual service.¹ ²

¹ NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 4-3.4.2; At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

² NFPA 10, 1998 Edition, Section, 4-4.4* Maintenance Recordkeeping; Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.

Based on observation, the facility failed to store oxygen cylinders in accordance with the standards of NFPA 99, 1999 Edition, Section 4-3.5.2.1. This deficiency affects 1 of 1 second floor smoke compartment.

Findings include:

During an observation on 9/13/16 at 12:42 p.m., respiratory therapy was inspected. There was a K-sized tank free standing in the room.¹

¹ NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 4-3.5.2.1; Gases in Cylinders and Liquefied Gases in Containers - Level 1, (a) Handling of Gases; requires administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility. (b)Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed: 27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Based on observation, the facility failed to store oxygen cylinders in accordance with the standards of NFPA 99, 1999 Edition, Section 4-3.5.2.1. This deficiency affects one smoke compartment on the main floor.

Findings include:

1. During an observation on 9/13/16 at 8:33 a.m., the ER restroom was was inspected. There was an E-sized oxygen tank free-standing in the room.¹

¹ NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 4-3.5.2.1; Gases in Cylinders and Liquefied Gases in Containers - Level 1, (a) Handling of Gases; requires administrative authorities shall provide regulations to ensure that standards for safe practice in the specifications for cylinders; marking of cylinders, regulators, and valves; and cylinder connections have been met by vendors of cylinders containing compressed gases supplied to the facility. (b)Special Precautions - Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed: 27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

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

Findings include:

1. During an observation on 9/13/16 at 3:30 p.m., the vaccine refrigerator was inspected. It was found to be plugged into the power strip in the room.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 observations and interview, the facility failed to maintain the electrical system and/or its components in accordance with NFPA 70, 1999 Edition, Article 110-26. This deficiency affects 1 of 1 smoke compartment.

Findings include:

During an observation on 9/13/16 at 2:56 p.m., the room in the back of the facility where the breaker panels were housed was inspected. The panels were found to be blocked by empty boxes and garbage cans.¹

¹ 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 3 1/2 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.