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The facility failed to conduct exercises to test the emergency plan annually.

Review of documentation and interview with staff determined the facility did not conduct a full-scale exercise in the past year. The most recent full scale exercise was conducted in October 2018.

Failure to conduct annual exercises to test the emergency preparedness plan increases the risk of injury or death due to fire.

This deficiency affected the entire facility.

One-story buildings of Type II (000) construction are required to be protected by an automatic sprinkler system. Without a sprinkler system, Type II (111) construction is required. 19.1.6.2 through 19.1.6.7.

The facility failed to provide a construction type that met the requirements of the Life Safety Code.

Observation determined the steel I-beams and columns were not protected as a one-hour fire rated assembly.
Failure to meet the requirements of building construction type increases the risk of death or injury due to fire.

This deficiency affected the entire facility.

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

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 the Code or as directed by the authority having jurisdiction. 4.6.12.4

Emergency illumination shall be provided for not less than 1½ hours in the event of failure of normal lighting. 7.9.2.1

Testing of required emergency lighting systems shall be permitted to be conducted as follows:

1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds.
2) The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
3) Functional testing shall be conducted annually for a minimum of 1½ hours if the emergency lighting system is battery powered.
4) The emergency lighting equipment shall be fully operational for the duration of the tests.
5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.9.3.1.1

The facility failed to ensure the emergency lighting was in proper operating condition to provide 1½ hours of emergency illumination in the event of failure of normal lighting.

Records review determined monthly 30-second tests of the emergency battery-powered emergency lighting system were not conducted during July 2019 through January 2020.

Failure to test and maintain the emergency lights in accordance with NFPA 101 increases the risk of death or injury due to fire.

The deficiency affected all emergency battery back-up lights throughout the building.

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

1) During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open. 7.2.1.4.3.1

Observation determined the corridor door to the old Elevator Equipment Room in the basement opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened.

The deficiency affected one (1) of numerous corridor doors in the means of egress throughout the facility.

2) 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 numerous items mounted on the walls throughout the facility in the corridors extended more than 4" into the means of egress.

This deficiency affected means of egress 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.

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

Observation determined the corridor door to the Middle Stairway in the basement failed to self-close and latch into the door frame.

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

This deficiency affected one (1) of three (3) means of egress from the basement.

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 and interview of staff determined no record was available to determine the most recent inspection and testing of the fire dampers.

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

This deficiency affected all fire dampers in the facility.

The facility failed to conduct fire drills as required.

No records were available to indicate fire drills were conducted during July through December 2019.

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

The deficiency affected six (6) of twelve (12) drills in the past year.

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 areas other than kitchens where receptacles are installed within 6 ft. of the outside edge of the sink shall have ground-fault circuit-interrupter protection for personnel. NFPA 70, 210.8, 210.8(A)(7)

The facility failed to provide electrical wiring and equipment in accordance with NFPA 70, National Electrical Code.

Observation determined electrical receptacles throughout the facility were installed within 6 ft. of a sink and were not ground-fault circuit-interrupter 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 numerous receptacles throughout the facility.

The facility failed to ensure the emergency generator was in compliance with NFPA 99 and NFPA 110.

1) Record review and interview with staff determined the emergency generator was not exercised under load for 4 continuous hours in the past 36 months.

2) Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:

(a) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.

(b) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating.

No record was available to indicate a 30-minute run test of the emergency power generator was conducted monthly.

Failure to inspect, test and maintain the emergency generator in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.

Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standards for Health Care Facilities. 19.3.2.4

Electrical devices should be physically protected, such as by use of a protective barrier around the electrical devices, or by location of the electrical device such that it will avoid causing physical damage to the cylinders or containers. For example, the device could be located at or above 1.5m (5 ft) above finished floor or other location that will not allow the possibility of the cylinders or containers to come into contact with the electrical device as required by this section. NFPA 99, A.5.1.3.3.2(5)

The facility failed to ensure nonflammable medical gas equipment and systems were in compliance with NFPA 99. In oxygen storage rooms containing more than 300 cu. ft. of gas, all electrical wall fixtures must be physically protected or located at least five (5) feet above the floor.

Observation determined the Oxygen Storage Room contained over 300 cu. ft. of oxygen and had a light switch that was unprotected and installed less than five (5) feet above the floor.

This deficiency affected one (1) of one (1) oxygen storage room in the facility.