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The facility failed to maintain a two-hour fire resistance-rated occupancy separation between the hospital and the attached clinic.

Observation determined the 90-minute fire resistance rated door in the occupancy separation barrier at the entrance to the tunnel connecting the hospital and the clinic was not equipped with a self-closing device.

Failure to ensure doors in the fire resistance rated occupancy separation barrier are self-closing increases the risk of injury or death due to fire.

This deficiency affected one (1) of two (2) connecting links in the two-hour fire resistance rated barrier separating the facilities.

The facility failed to maintain the means of egress in accordance with Chapter 7.

Means of egress must be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. The width of means of egress shall be measured in the clear at the narrowest point of the exit component under consideration. Exception: Projections not more than 4 1/2 in. (114 mm) on each side shall be permitted at 38 in. (965 mm) and below. 7.1.10.1, 7.3.2.2

The 2010 Standards for Accessible Design generally limit the protrusion of wall-mounted objects into corridors to no more than 4 inches from the wall when the object's leading edge is located more than 27 inches, but not more than 80 inches, above the floor.

Observation determined:

1) A wall mounted mirror in the first-floor west wing corridor extended 15-inches from the wall at approximately 74-inches from the floor.
2) A wall mounted clock in the third-floor west wing corridor extended 18-inches from the wall at approximately 76-inches from the floor.

This deficiency affected egress from two (2) of numerous exit corridors throughout the facility.

Failure to maintain the means of egress to be available at all times increases the risk of death or injury due to fire.

Exits must terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge must be of required width and size to provide all occupants with safe access to a public way. 19.2.7, 7.7.1

To ensure adequate exit capability, CMS requires asphalt or concrete surfaces from exterior exits to public ways. CMS S&C-05-38

The facility failed to provide all occupants with safe access to a public way.

Observation determined the west exterior exit discharge traversed the lawn to get to a public way.

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

The deficiency affected one (1) of three (3) paths of egress from the facility.

The facility failed to ensure vertical openings were enclosed with construction having a fire-resistance rating of at least 1-hour.

Observation determined the 60-minute fire resistance rated double set of doors in front of the second-floor elevator shaft did not self-close. The door coordinator device did not operate correctly and an astragal on the second door leaf prevented the doors from completely closing.

Failure to protect vertical openings increases the risk of injury or death due to fire.

This deficiency affected one (1) of two (2) elevator shafts in the facility.

Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 19.3.2.1

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

Observation determined the door separating the first-floor Mechanical Room and the Staff Restroom lacked a self-closing device.

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

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

In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow or closer than 36 in. from an air supply diffuser or return air opening. 19.3.4.5.1, 9.6.2.10.1.1, NFPA 72 17.7.4.1, A.17.7.4.1

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

Observation determined a smoke detector in the West Wing corridor on the first-floor near Dietary Room 101 was installed within 36 in. of an air supply vent.

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

This deficiency affected one (1) of numerous smoke detectors in the facility.

Portable fire extinguishers shall be provided in all health care occupancies. Extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 19.3.5.12, 9.7.4.1

Fire extinguishers having a gross weight not exceeding 40 lb. (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb. (18.14 kg) (except wheeled types) shall be installed so that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 in. (102 mm). NFPA 10 6.1.3.8.1, 6.1.3.8.2, 6.1.3.8.3

The facility failed to install fire extinguishers in accordance with NFPA 10.

Observation determined portable fire extinguishers throughout the facility were installed with the top of the extinguisher more than 5 ft. above the floor.

Failure to install fire extinguishers in accordance with NFPA 10 increases the risk of injury or death due to fire.

The deficiency affected numerous fire extinguishers in the facility.

Fire dampers shall be tested and inspected in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. All tests shall be completed in a safe manner by personnel wearing personal protective equipment. Full unobstructed access to the fire or combination fire/smoke damper shall be verified and corrected as required. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts. The damper frame shall not be penetrated by any foreign objects that would affect fire damper operations. The damper shall not be blocked from closure in any way. The fusible link shall be reinstalled after testing is complete. If the link is damaged or painted, it shall be replaced with a link of the same size, temperature, and load rating. All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. All documentation shall be maintained and made available for review by the AHJ. 19.5, NFPA 80, 19.4

The facility failed to test and inspect fire dampers as required by NFPA 80.

Record review indicated the fire damper in the second-floor Conference Room was visually inspected and has not been physically tested in the past 6 years.

Failure to maintain fire dampers in accordance with NFPA 80 increases the risk of death or injury due to fire.

This deficiency affected one (1) of numerous fire dampers in the facility.

Ground-fault circuit-interruption for personnel shall be provided as required. The ground-fault circuit-interrupter shall be installed in a readily accessible location. All 125-volt, single-phase, 15- and 20-ampere receptacles located in bathrooms, kitchens and where receptacles are installed within 6 ft. of the outside edge of the sink shall have ground-fault circuit-interrupter protection for personnel. 19.5.1.1, 9.1.2, NFPA 70, 210.8, 210.8(B)(1), 210.8(B)(2), 210.8(B)(5)

The facility failed to ensure electrical wiring and electrical equipment met the requirements of NFPA 70, National Electrical Code.

Observation determined an electrical outlet in Room 112 on the first-floor was within 6' of a sink and was not GFCI protected.

Failure to provide electrical wiring and equipment in accordance with NFPA 70 increases the risk of injury or death due to fire.

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

The facility failed to conduct fire drills as required.

Fire drill records review determined fire drills did not include the simulation of an emergency phone call to the fire department.

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

The deficiency affected twelve (12) of twelve (12) drills in the past year.