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Based on record review, observation and staff interview, the facility failed to maintain a two-hour fire barrier as designed. This deficient practice of not maintaining a two-hour fire rated barrier as designed affects the ability of the facility to comply with the original design of the building and affects all patients in both smoke zones. The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings include:

During the survey on March 12, 2019 it is observed that the two-hour fire barrier indicated on the original construction documents and the 2015 code foot print has the following deficiencies:

1. At 2:00 pm on the wall diving the LTC unit from the hospital the West side of the duct work, on the hospital side of the wall, has a gap around it going through the two-hour fire wall.

2. At 2:00 pm the fire wall doesn't extend from exterior wall to exterior wall. The metal studs on the exterior wall are visible and have a 2-inch x 3-inch oval penetration that is visible.

3. At 2:05 pm the fire rated doors between the green and yellow compartment are in a 2-hour rated wall and are 45- min rated doors not 90-min rated doors as required.

4. At 3:00 pm there is a half inch hole in the fire wall above the ceiling above the time clock near the vending area.

5. At 3:05 pm there is a 1.5-inch penetration that has ½ inch conduit running through the fire wall right above the west entrance of the hospital.

Staff B was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Fire barriers used to provide enclosure, subdivision, or protection under this Code shall be classified in accordance with one of the following fire resistance ratings:

(1) 3-hour fire resistance rating
(2) 2-hour fire resistance rating
(3) I-hour fire resistance rating
(4) ½ -hour fire resistance rating
Fire barriers shall comply with one of the following:

(1) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
(2) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, and from the floor to the bottom of the interstitial space, provided that the construction assembly forming the bottom of the interstitial space has a fire resistance rating not less than that of the fire barrier.

Walls used as fire barriers shall comply with Chapter 7 of NFPA 221, Standard for High Challenge Fire Walls, Fire Walls, and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply. 2012 NFPA 101, 8.3.1.1, 8.3.1.2 and 8.3.1.3

Based on observation and record review, the facility failed to provide complete documentation of annual inspection and testing of the fire alarm system as required by NFPA 72. The absence of complete, verifiable documented maintenance and repair history on the fire alarm system fails to ensure reliability of the alarm system in the event of an emergency, affecting all patients in one of two smoke zones. The facility has a capacity of 12 and census of 3 at the time of the survey.

Findings include:

It is observed on March 12, 2019 no documentation is available for review for the monthly testing of single station smoke detectors that are installed in the patient rooms on the med surge floor.


Staff B was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 2012 NFPA 101, 19.3.4.1

Review of the following NFPA Standard revealed: 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. 2012 NFPA 101, 4.6.12.4

Review of the following NFPA Standard revealed: To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 2012 NFPA 101, 9.6.1.5

Review of the following NFPA Standard revealed: 14.6.2.4* A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested
(8) Functional test of detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Test of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer's published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)

Based on observation and interview the facility fails to ensure that the facility's automatic sprinkler system is being inspected, tested and maintained in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting all patients in all smoke zones. The facility has a capacity of 12 and census of 3 at the time of the survey.

Findings include:

Record review conducted March 12, 2019 of the facility's sprinkler inspection, testing and maintenance records for the last six quarters revealed that the following:

1. There is no documentation of weekly inspection of dry sprinkler system gauges is available for review prior to October 2018.

Staff B was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2012 NFPA 101, 9.7.5

Review of the following NFPA Standard revealed: Gauges on dry, preaction, and deluge systems shall be
inspected weekly to ensure that normal air and water pressures are being maintained. Where air pressure supervision is connected to a constantly attended location, gauges shall be inspected monthly.2011 NFPA 25, 5.2.4.2 and 5.2.4.3

Review of the following NFPA Standard revealed: Waterflow alarm and supervisory alarm devices shall be inspected quarterly to verify that they are free of physical damage. 2011 NFPA 25, 5.2.5

Review of the following NFPA Standard revealed: Mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly. 2011 NFPA 25, 5.3.3.1

Review of the following NFPA Standard revealed: Testing waterflow alarm devices on dry pipe, preaction, or deluge systems shall be accomplished by using the bypass connection. 2011 NFPA 25, 5.3.3.5

Review of the following NFPA Standard revealed: Each control valve shall be operated annually through its full range and returned to its normal position. Post indicator valves shall be opened until spring or torsion is felt in the rod, indicating that the rod has not become detached from the valve. Post indicator and outside screw and yoke valves shall be backed a one-quarter turn from the fully open position to prevent jamming. 2011 NFPA 25, 13.3.3.1 through 13.3.3.3

Review of the following NFPA Standard revealed: Record Keeping and maintenance records required by NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, shall be maintained at an approved, secured location. 2012 NFPA 101, 9.7.8

Based on record review and staff interview, the facility is not conducting, and documenting fire drills as required. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all patients in both smoke zones. The facility has a capacity of 12 and census of 3 at the time of the survey.

Findings include:

During record review on March 11, 2019 the following is revealed:

1. Review of fire drill records for the last 6 quarters revealed fire drill documentation on scenarios is not complete. Fire drill 12/30/18 scenario is documented as "Fire in ED storage". No detailed scenario is given.

2. The fire Drill on Friday 9-28-18 was silent and alarms were set off on Monday 10-1-18.

Staff B was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 2012 NFPA 101, 19.7.1.4

Review of the following NFPA Standard revealed: Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. 2012 NFPA 101, 19.7.1.6

Based on observation and staff interview, the facility fails to ensure that outlets throughout the facility at wet locations are installed in accordance with the requirements NFPA 70 National Electrical Code. This deficient practice increases the risk of electrical shock or an electrical fire and affects all patients in both smoke zones. The facility has a capacity of 12 and census of 3 at the time of the survey.

Findings include:

During the survey on March 12, 2019 the following is observed:

1. At 3:20 pm no documentation is available for review showing that the outlets in the laboratory at wet locations are GFCI protected.


Staff B was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: 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. 2012 NFPA 101, 9.1.2


Review of the following NFPA Standard revealed: In no case shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in 210.23(A) through (D) and as summarized in 210.24 and Table 210.24. 2011 NFPA 70, 210.23

Review of the following NFPA Standard revealed: Ground-Fault Circuit-Interrupter Protection for Personnel. Ground-fault circuit-interruption for personnel shall be provided as required in 210.8(A) through (C). The ground-fault circuit-interrupter shall be installed in a readily accessible location.
Informational Note: See 215.9 for ground-fault circuit-interrupter protection for personnel on feeders.

(B) Other Than Dwelling Units. All 125-volt, single phase, 15- and 20-ampere receptacles installed in the locations
specified in 210.8(B)(1) through (8) shall have ground-fault circuit-interrupter protection for personnel.
(1) Bathrooms
(2) Kitchens
(3) Rooftops
(4) Outdoors

Exception No. 1 to (3) and (4): Receptacles that are not readily accessible and are supplied by a branch circuit dedicated to electric snow-melting, deicing, or pipeline and vessel heating equipment shall be permitted to be installed in accordance with 426.28 or 427.22, as applicable.

Exception No. 2 to (4): In industrial establishments only, where the conditions of maintenance and supervision ensure that only qualified personnel are involved, an assured equipment grounding conductor program as specified in 590.6(B)(2) shall be permitted for only those receptacle outlets used to supply equipment that would create a greater hazard if power is interrupted or having a design that is not compatible with GFCI protection.

(5) Sinks - where receptacles are installed within 1.8 m (6 ft) of the outside edge of the sink.

Exception No. 1 to (5): In industrial laboratories, receptacles used to supply equipment where removal of power would introduce a greater hazard shall be permitted to be installed without GFCI protection.

Exception No. 2 to (5): For receptacles located in patient bed locations of general care or critical care areas of health care facilities other than those covered under 210.8(B)(1), GFCI protection shall not be required.

(6) Indoor wet locations
(7) Locker rooms with associated showering facilities
(8) Garages, service bays, and similar areas where electrical diagnostic equipment, electrical hand tools, or portable lighting equipment are to be used. 2011 NFPA 70, 210. 8

Based on record review and staff interview the facility fails to provide a documented maintenance and testing program for electrical systems. This deficient practice prevents the facility from ensuring that electrical systems are maintained and testing as required by NFPA 99 Health Care Facilities and could adversely affect all patients in both smoke zones. The facility has a capacity of 12 with a census of 3 patients at the time of the survey.

Findings include:

During the survey on March 11, 2019 it is noted that the documented maintenance and testing program that is available for hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered is not based on an itemized list. All receptacles are being tested but documentation is per circuit and they are labeling the documentation with how many duplex outlets are on each circuit in each room.

Staff B was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: A record shall be maintained of the tests required by this chapter and associated repairs or modification. At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter.
2012 NFPA 99, 6.3.4.2.1.1 and 6.3.4.2.1.2

Based on record review and staff interview the facility failed to assure the generator is installed, inspected and tested in accordance with NFPA 110 Standard for Emergency and Standby Power Systems. This deficient practice fails to ensure that the generator will not fail when needed in the event of an emergency, affecting all patientss both smoke zones. The facility has a capacity of 12 and census of 3 at the time of the survey.

Findings include:

During the survey on March 12, 2019 it is observed that no documentation is available for review for the March, April, and October 2018 monthly tests of the generator.

Staff B was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Where required for compliance with this Code, emergency generators and standby power systems shall comply with 9.1.3.1 and 9.1.3.2. 2012 NFPA 101, 9.1.3

Review of the following NFPA Standard revealed: Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 2012 NFPA 101, 9.1.3.1

Review of the following NFPA Standard revealed: EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. 2010 NFPA 110, 8.4.1

Review of the following NFPA Standard revealed: A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.

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. 2010 NFPA 110, 8.3.4, 8.3.4.1

Review of the following NFPA Standard revealed: EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. 2010 NFPA 110, 8.4.1

Review of the following NFPA Standard revealed: All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.
The remote manual stop station shall be labeled. 2010 NFPA 110, 5.6.5.6, 5.6.5.6.1

Based on observation and staff interview, the facility fails to ensure that mobile carts in the facility are plugged into UL1363A lists relocatable power taps. NFPA 99. This deficient practice increases the risk of electrical shock or an electrical fire and affects all patients in both smoke zones. The facility has a capacity of 12 and census of 3 at the time of the survey.

Findings include:

During the survey on March 12, 2019 it is observed that at 3:45 pm the medical device Mobil cart in the CT room is plugged into a universal power supply that does not have a UL 1363A listing.


Staff B was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: 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. 2012 NFPA 101, 9.1.2

Review of the following NFPA Standard revealed: Where used as permitted in 400.7(A)(3), (A)(6), and (A)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet or cord connector body.

Exception: As permitted in 368.56. 2011 NFPA 70, 400.7

Review of the following NFPA Standard revealed: Unless specifically permitted, flexible cords and cable shall not be used as a substitute for fixed wiring of a structure. 1999 NFPA 70, 400-8

Review of the following NFPA Standard revealed: In no case shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in 210.23(A) through (D) and as summarized in 210.24 and Table 210.24. 2011 NFPA 70, 210.23

Review of the following NFPA Standard revealed: The flexible cord, including the grounding conductor, shall be of a type suitable for the particular application; shall be listed for use at a voltage equal to or greater than the rated power line voltage of the appliance; and shall have an ampacity, as given in Table 400.5(A) of NFPA 70, National Electrical Code, equal to or greater than the current rating of the device. 2012 NFPA 99, 10.2.3.1.1

Review of the following NFPA Standard revealed: Nonpatient care-related electrical equipment, including facility- or patient-owned appliances that are used in the patient care vicinity and will, in normal use, contact patients, shall be visually inspected by the patient's care staff or other personnel. 2012 NFPA 99, 10.4.2.1