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Based on observations and staff interview, the facility failed to ensure that stairways used as exits are in compliance with the 2012 edition of NFPA 101 Life Safety Code.

Chapter 4, section 4.5.8 (Maintenance) states that whenever or wherever any device, equipment,
system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained, unless the Code exempts such maintenance.

Chapter 19, section 19.2.2.3 states stairs complying with 7.2.2 shall be permitted.

Section 7.2.2.5.1.1 states all inside stairs serving as an exit or exit component, shall be protected in accordance with 7.1.3.2.

Section 7.1.3.2.1 states where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following:
(1) The separation shall have a minimum 1-hour fire resistance rating where the exit connects three or fewer stories.
(2) The separation specified in 7.1.3.2.1(1), other than an existing separation, shall be supported by construction having not less than a 1-hour fire resistance rating.
(3) The separation shall have a minimum 2-hour fire resistance rating where the exit connects four or more stories, unless one of the following conditions exists:
(a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating.
(b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating.

Section 8.2.2.2 states fire compartments shall be formed by fire barriers complying with 8.3.

Table 8.3.4.2 requires vertical shafts, including stairways, exits and refuse chutes with a fire resistance rating of 1-hour to be equipped with a 1-hour fire rated door assembly.

Section 8.3.4.3 states existing fire door assemblies having a minimum 3/4-hour fire protection rating shall be permitted to be continued to be used in vertical openings and in exit enclosures in lieu of the minimum 1-hour fire protection rating required by table 8.3.4.2.

Findings Include:

During the morning and afternoon hours of 5/07/18, it was observed that each stair tower is designed as a two hour fire rated assembly.

The following items were noted as deficient:

Stairwell Number 3:
-The door labels on stair doors at the ground floor and the eighth floor level were painted.
-The door label on the fifth floor level had been removed.
-The ninth floor level stair door had the cylinder latch replaced with a smaller latch mechanism, exposing two 1/2" diameter holes through the door face.

Stairwell Number 4:
-The door label on the stair door at the eighth floor level was painted.
-The stair door label on the fifth floor level had been removed.
-The fourth floor level stair door had the cylinder latch replaced with a smaller latch mechanism, exposing two 1/2" diameter holes through the door face, and the clearance between the bottom of the door.
-The clearance between the bottom of the eighth floor level stair door and the floor level is approximately 1 inch (exceeding the 3/4" allowable)

Because the stair doors noted above are not equipped with a fire rated door tag, each enclosure can not be verified as a 2-hour fire rated enclosure. As a result, the fire rating of the door could not be confirmed and was found to be non-compliant with Section 8.3.4.3

The findings were confirmed by and reviewed with Administrative staff during the exit interview conference

Based on observations the facility failed to ensure that all hazardous areas are protected in accordance with the 2012 edition of NFPA 101 Life Safety Code.

Section 19.3.2.1 states any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1.

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

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

Section 19.3.2.1.3 states the doors shall be self-closing or automatic-closing.
- Section 19.3.2.1.5 states hazardous areas shall include, but shall not be restricted
to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal (242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

-Section 7.2.1.8.1* states a door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3.

Findings Include:

Observations while touring the facility on 5/07/18 revealed the following on the basement level:

1. The egress corridor located outside of the Gym/Exercise room is being used as a permanent storage area for at least twenty-nine (29) 45 gallon and twelve (12) 96 gallon shredded paper recycle bins.

2. The corridor doors to the "Bulk Storage Room (labeled "Storage and Shops"), the Mechanical Room, the Main Electrical Room, and the Emergency Electric Room have a ½" gap at the meeting edge of their respective door leafs.

3. The corridor door the Steam (power) Room had the latch mechanism removed so that the door did not latch in the frame.

As a result, the facility failed to comply with section 19.3.2.1 requiring hazardous areas/locations to be properly separated and is non-compliant with Section 19.3.2.1.3. Doors to hazardous areas must be self-closing or equipped with an automatic closing device compliant with Chapter 7 of the 2012 edition of NFPA 101 Life Safety Code.

The findings were confirmed by and reviewed with Administrative staff during the exit conference.

Based on observations and confirmed by staff the facility failed to ensure compliance with Chapter 19.
Section 19.3.6.3.1 states that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:
(1) 1-3/4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes

Section 19.3.6.3.2 states that the requirements of 19.3.6.3.1 shall not apply where otherwise permitted by either of the following:
(1) Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain
flammable or combustible materials shall not be required to comply with 19.3.6.3.1.
(2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

Section 19.3.6.3.5 states that corridor doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.

Findings Include:

On 05/07/18 the following was noted:

1. The 44" wide corridor doors to patient rooms on the fourth, fifth, and eighth floor level units are equipped with a 24" X 50" door within a door. When closed each interior door has an approximate 6" long x 1/4" unsealed gap at the latch side of the door within a door. As a result, none of the patient room doors are smoke tight. In addition, the corridor door at patient room #447 has approximately 12" of the door gasket along the inner doors' header, creating an additional 12" x 1/4" gap.

2. The 44" wide corridor door to the group / OT Therapy Room, #463, had 21" x 37" rough opening where a window was removed, leaving the room open to the corridor.

3. The corridor door to the ground floor level "Gun Locker," labeled #114 has an unsealed 12" x 2" opening through the door.

As a result of the finding the facility is found to be non-compliant with section 19.3.6.3.2(2)

The findings were confirmed by and reviewed with Administrative staff during the exit conference.

Based on observations and confirmed by staff, the facility failed to ensure that fire drills are conducted quarterly on each shift utilizing various times and conditions.

Findings Include:

During the morning hours of 5/7/18 while performing the record review process, it was observed that the fire drills were not conducted as required. The fire drills for the 1st shift (7:00 A.M.- 3:00 P.M.), 2nd shift (3:00 P.M.- 11:00 P.M.) and 3rd shift (11:00 P.M.-7:00 A.M.) were documented as occurring at the following times:

1st Shift: 2/28/18 @ 10:07 A.M.; 11/30/17 @ 10:35 A.M.; 8/31/17 @ 9 :45 A.M.; and 4/27/17 @ 10:05 A.M.

2nd Shift: 4/30/18 @ 3:33 P.M.; 1/31/18 @ 3:30 PM.; 10/24/17 @ 3:30 P.M.; 7/31/17 @ 3:35 P.M.; and 5/31/17 @ 3:35 P.M.

3rd Shift: 3/30/18 @ 6:08 A.M.; 12/30/17 @ 6:05 A.M.; 9/29/17 @ 6 :04 A.M.; and 6/13/17 @ 6:15 A.M.

The following deficiencies were noted after reviewing the fire drills:

1) The fire drills conducted on the 1st Shift were not held at varying times and conditions as required. All of the drills were performed between 9:45 A.M. and 10:35 A.M.

2) The fire drills conducted on the 2nd Shift were not held at varying times and conditions as required. All of the drills were performed between 3:30 P.M. and 3:35 P.M.

3) The fire drills conducted on the 3rd Shift were not held at varying times and conditions as required. All of the drills were performed between 6:04 A.M. and 6:15 A.M.

As a result of the performed drills, the facility failed to comply with section 19.7.1.4.

This was confirmed by the Administrative staff during the exit interview conference.

Based on observations and record review, the facility failed to ensure a door inspection program is performed and documented as such. Section 19.7.6 states maintenance and testing shall comply with section 4.6.12.

Section 4.6.12.1 states whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

Section 4.6.12.2 states no existing life safety feature shall be removed or reduced where such feature is a requirement for new construction.

Section 4.6.12.3 states existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

Section 4.6.12.4 states any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

Section 4.6.12.5 states maintenance, inspection, and testing shall be performed under the supervision of a responsible person who shall ensure that testing, inspection, and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.

Section 8.3.3.1 states openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in this Code.

NFPA 80 section 5.2.1 states fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

Section 5.2.3.1 states functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.

Section 5.2.4.1 states fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.

Section 5.2.4.2 states as a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

Findings Include:

During the morning hours of 5/7/18 while performing the record review process, it was revealed that the doors within the facility are not inspected/tested as required. Although facility staff inspects doors during routine inspections, the doors are not listed out individually in regards to the inspection criteria applied to that specific door application. In addition, there is no documentation to substantiate that non-rated doors such as patient room doors are inspected as well.

As a result, the facility failed to comply with section 19.7.6 and NFPA 80.

This was confirmed by the Administrative staff during the exit interview conference.

Based on observations the facility failed to ensure compliance with Section 9.1.2 of the 2012 edition of NFPA 101 Life Safety Code. The facility failed to ensure that the electrical system in the Main Electrical room is maintained as required.

Chapter 4, section 4.5.8 (Maintenance) states that whenever or wherever any device, equipment,
system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained, unless the Code exempts such maintenance.

Section 9.1.2 states that electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

Article 110.11 Deteriorating Agents. Unless identified for use in the operating environment, no conductors or equipment shall be located in damp or wet locations; where exposed to gases, fumes, vapors, liquids, or other agents that have a deteriorating effect on the conductors or equipment; or where exposed to excessive temperatures.

Article 110.26 Spaces About Electrical Equipment. Access and electrical equipment to permit ready and safe operation and maintenance of such equipment.
(E) Dedicated Equipment Space. All switchboards, panelboards, and motor control centers shall be located in dedicated spaces and protected from damage.

NFPA 110 (7.2 Location.) Section 7.2.1.1 states that the room shall have a minimum 2-hour fire rating or
be located in an adequate enclosure located outside the building capable of resisting the entrance of snow or rain at a maximum wind velocity required by local building codes.

Section 7.2.1.2 states that no other equipment, including architectural appurtenances, except those that serve this space, shall be permitted in this room.

Section 7.2.3, states that the rooms, shelters, or separate buildings housing Level 1 or Level 2 EPSS equipment shall be designed and located to minimize the damage from flooding, including that caused by the following:
(1) Flooding resulting from fire fighting
(2) Sewer water backup
(3) Similar disasters or occurrences

Section 7.2.4, states that minimizing the possibility of damage resulting from interruptions of the emergency source shall be a design consideration for EPSS equipment.

Findings Include:

1. On 5/7/18, water was observed on the floor of the basement level Main Electric and Emergency Electric Rooms. The water was puddled on the floor in both locations and was observed dripping in from the foundation wall around the electrical feeder conduits.

2. The 1-1/2 hour fire rated, 36" wide fire door separating the Main Electrical and Emergency Electrical equipment had the 5" x 20" vision panel and latch mechanisms removed. As a result, there is no longer a vision panel nor a door latch provided leaving voids in the door.

As a result, the spaces about the electrical equipment were not maintained in accordance with NFPA 70, Articles 110.11 and 110.26 and NFPA 110 section Section 7.2.1.1 .

This was confirmed by and reviewed with the Administrative staff during the exit interview conference.

16934

Based on observations and records provided, the facility failed to properly maintain the automatic emergency generator system.

NFPA 99 section 6.4.4.1.1.3 states maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8.

NFPA 99 section 6.4.4.1.1.4 states the inspection/testing. criteria, conditions, and personnel requirements shall be in accordance with 6.4.4.1.1.4(A) through 6.4.4.1.1.4(C).
(A)* Test Criteria. Generator sets shall be tested 12 times a year, with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8.
(B) Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
(C) Test Personnel. The scheduled tests shall be conducted by competent personnel to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.

NFPA 110 section 8.3.1 states the Emergency Power Supply System (EPSS) shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.

Section 8.3.4 states a permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.

Section 8.3.2 states a routine maintenance and operational testing program shall be initiated immediately after the EPSS has passed
acceptance tests or after completion of repairs that impact the operational reliability of the system.

Section 8.3.4.1 states the permanent record shall include the following:
(1) The date of the maintenance report.
(2) Identification of the servicing personnel.
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced.
(4) Testing of any repair for the time as recommended by the manufacturer.

Section 8.4.1 states EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

Findings Include:

During the morning hours of 5/7/18 while reviewing the generator log book, it was revealed that the maintenance and testing of the emergency generator was not performed as required.

While reviewing the generator log book, it was revealed that the hospital is currently utilizing a 400 kW temporary generator to supply emergency power. After reviewing the past year of generator testing documentation, it was revealed that the generator was having significant on-going maintenance issues. It was indicated on numerous weekly in-house testing reports that the unit would shut down under a low fuel pressure and low oil pressure trouble safety. It was further indicated on the 8/29/17 weekly test that the unit failed to start all together due to an oil pressure trouble issue. After talking with the Director of Safety and Security, it was confirmed that the generator was no longer operational at this point in time.

As indicated above, the Hospital's generator was no longer functional as of 8/29/17. According to the Director of Safety and Security, the generator vendor was contacted at this time to secure a temporary generator for the hospital. According to interview, the temporary generator was not delivered to the hospital until 10/17/17. It was further stated that the temporary generator was not connected into the hospital's electrical system until 11/3/17. In addition, the hospital could not provide the surveyor with actual documentation showing the delivery and installation dates of the temporary unit. The first documented test of the temporary unit available for review was performed by the Hospital's in-house staff and dated 11/13/17.

As a result of the Hospital's original generator being non-operational and a rental unit installed, the Hospital did not act in a timely manner to ensure emergency power was provided as required. The generator was first noted as non-functional on 8/29/17 by facility maintenance personnel. However, a rental generator was not secured and tied into the hospital's electrical system until 11/3/17. The facility exceeded a 2-month period without having the required backup emergency electrical source.
Note: As there was no actual delivery and installation documentation provided, the exact date of temporary generator installation is not known. As stated above, the first documented testing of the temporary unit is 11/13/17.

As a result of the non-operational generator, the facility failed to comply with NFPA 99 and NFPA 110 requiring generators to be properly maintained and tested.

This was confirmed by the Administrative staff during the exit interview conference.

Note: The Hospital is in the process of having two (2) 250 kW emergency generators installed to replace the failed unit. The Hospital was advised during the exit interview to ensure all of the required acceptance testing outlined in NFPA 110 is performed, documented, and obtained for future review.