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During the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, NFPA 220 (2012) and NFPA 5000 (2012). This was evidenced by:

1. Two storage closets, on the west side side of the property near the oxgen storage area, do not meet 2-hour separation requirements between healthcare and non-healthcare occupancies.

NFPA 101 8.2.1.2* NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction
classification. 19.1.1.4.1 Additions. Additions shall be separated from any existing structure not conforming to the provisions within
Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. (See 4.6.7 and 4.6.11.) 19.1.3.3* Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
(1) They are not intended to provide services simultaneously for four or more inpatients for purposes of housing, treatment, or customary access by inpatients incapable of self-preservation.
(2) They are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8.
(3) For other than previously approved occupancy separation arrangements, the entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

NFPA 220 5.1.10 Structural elements within an exterior wall located where openings are not permitted, or where protection of openings is required in accordance with 7.3.5 of NFPA 5000, Building Construction and Safety Code, shall have a fire resistance rating based on protection against exterior fire exposure as required for exterior bearing walls or the structural element, whichever requires the greater fire resistance rating. [5000:7.2.7.10]

NFPA 5000 7.2.7.10 Structural elements within an exterior wall located where openings are not permitted, or where protection of openings is required in accordance with 7.3.5, shall have a fire resistance rating based on protection against exterior fire exposure as required for exterior bearing walls or the structural element, whichever requires the greater fire resistance rating.
Table 7.3.2.1 Fire Resistance Ratings for Exterior Walls (hr).

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Facility CEO and Director of Maintenance during the exit conference.

During the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101. This was evidenced by:

1. East patio egress gates require special knowldege and more than one motion to open.
2. Exit doors from kitchen and employee dining hall do not open into the exit corridor. Metal trim between the door leaves do not allow the door to open from the closed postion.
3. An isolation barrier in Acute Care Room 7 impedes egress from the room.

NFPA 101 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by one of the following:
(1) Locks complying with 19.2.2.2.5 shall be permitted.
(2)* Delayed-egress locks complying with 7.2.1.6.1 shall be permitted.
(3)* Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.
(4) Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted.
(5) Approved existing door-locking installations shall be permitted.

NFPA 101 7.2.1.5.1 Door leaves shall be arranged to be opened readily from the egress side whenever the building is occupied.

NFPA 101 7.1.10.1* General. 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.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Facility CEO and Director of Maintenance during the exit conference.

During the survey, it was determined that the facility failed to meet the operational requirements in accordance with NFPA 101 (2012). This was evidenced by:

1. Missing exit signage indicating direction of travel at the bottom of the stairwell next to the basement Meeting Room.

NFPA 101 7.10.1.2.2* Horizontal components of the egress path within an exit enclosure shall be marked by approved exit or directional exit signs where the continuation of the egress path is not obvious.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Facility CEO and Director of Maintenance during the exit conference.

During the survey, it was determined that the facility failed to meet operational requirements in accordance with NFPA 101. This was evidenced by:

1. Missing monthly exit light inspection/testing/mainteance reports prior to January 2023.

7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1.1 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, except as otherwise permitted by 7.9.3.1.1(2).
(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 11/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Facility CEO and Director of Maintenance during the exit conference.

During the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 (2012). This was evidenced by:

1. Salon door does not possess self-closing hardware tied to the fire alarm system. Aerosol cans were stored within room.

NFPA 101 19.3.6.3.1, in part, requires doors protecting openings in a corridor to be constructed to resist the passage of smoke. Section 19.3.6.3.5, in part, doors shall be provided with means for keeping the doors closed, the device shall be capable of keeping the door closed when 5 lb is applied to the latch side of the door. 19.3.2 Protection from Hazards. 19.3.2.1.3 The doors shall be self-closing or automatic-closing.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Facility CEO and Director of Maintenance during the exit conference.

During the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 (2012), NFPA 96-Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (2011), 17A-Standard for Wet Chemical Extinguishing Systems (2009) and NFPA 54-National Fuel Gas Code (2012). This was evidenced by:

1. Wheeled, gas fueled appliances did not have their safety tethers attached.
2. Wheeled appliances did not have wheel chocks or floor markings to show correct location under kitchen hood suppression system.

NFPA 54 (2012) 9.6.1.1 Commercial Cooking Appliances. Commercial cooking appliances that are moved for cleaning and sanitation purposes shall be connected in accordance with the connector manufacturer's installation instructions using a listed appliance connector complying with ANSI Z21.69/CSA 6.16, Connectors for Movable Gas Appliances. The commercial cooking appliance connector installation shall be configured in accordance with the manufacturer ' s installation instructions.9.6.1.2 Restraint-Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer's installation instructions.

NFPA 96 (2011) 12.1.2.3.1 An approved method shall be provided that will ensure that the appliance is returned to an approved design location.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Facility CEO and Director of Maintenance during the exit conference.

During the survey, it was determined that the facility failed to maintain the fire alarm system in accordance with NFPA 101 and NFPA 72 (2010). This was evidenced by the following:

1. Missing two (2) year smoke detector sensitivity testing report.
2. Fire Alarm Control Panel electrical breaker was not secured from unauthorized acces (Panel E in Main Electrical Room).

NFPA 101 19.3.4.1 to comply with section 9.6. Section 9.6.1.3, fire alarm system testing and maintenance to comply with NFPA 72.
-NFPA 72 14.4.5.3.4; to ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose

NFPA 72 10.5.5.2 Circuit Identification and Accessibility. 10.5.5.2.4 The circuit disconnecting means shall be accessible only to authorized personnel.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Facility CEO and Director of Maintenance during the exit conference.

During the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, NFPA 25 (2011) and NFPA 13 (2010). This was evidenced by:

1. There is a gap around the fire sprinkler head in the lab/copy room hallway drop ceiling.
2. Several fire sprinkler system guages are five years old or older (main building and CT scan suite).
3. Main building fire sprinkler riser is missing a hydraulic design inforrmation sign.
4. Dry fire sprinklers protecting the abulance bay were manufactured in 2010.
5. Missing two (2) fire sprinkler quarterly inspection/testing/maintenance reports from the last 12 months.
6. Missing three (3) year dry valve trip test inspection/testing/maintenance report.
7. Missing five (5) year internal obstruction inspection/testing/maintenance reports for dry and anti-freeze fire sprinkler systems.
8. Fire sprinkler system backflow report from 10/13/22 showed equipment failed testing.

NFPA 25 5.1.1.2 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

NFPA 25 5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge.

NFPA 25 5.2.6* Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.

NFPA 25 5.3.1.1.1.6* Dry sprinklers that have been in service for 10 years shall be replaced or representative samples shall be tested and then retested at 10-year intervals.

NFPA 101 4.6.12.1 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.

NFPA 25 13.4.5.2.5.2 Records of dry pipe valve tripping time and water transit delivery time to the inspector's test connection shall be maintained for full flow trip tests.

NFPA 25 14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material.

NFPA 25 4.1.4* Corrections and Repairs. 4.1.4.1 The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by this standard. 4.1.9.2 Where a water-based fire protection system is returned to service following an impairment, the system shall be verified to be working properly by means of an appropriate inspection or test.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Facility CEO and Director of Maintenance during the exit conference.

During the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 (2012) and NFPA 10 (2010). This was evidenced by:

1. Missing annual fire extinguisher inspection/testing/mainteance report.

NFPA 10 7.3.1.1.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Facility CEO and Director of Maintenance during the exit conference.

During the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:

1. Main electrical room has penetrations in ceiling.
2. Penetrations above the ceiling at smoke compartment boundaries (above doorways between Admin Hall and Acute Care/ER wing & Admin Hall/Extended Care Wing).

NFPA 101 19.3.7.3, in part, smoke barrier walls constructed in accordance with Section 8.5 with a minimum of 1/2-hour fire resistive rating. Section 8.5.1, in part, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.

NFPA 101 19.3.7.3 to comply with section 8.5. Section 8.5.6.2, in part, penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Facility CEO and Director of Maintenance during the exit conference.

During the survey, it was determined the facility failed to maintain the building services for electrical equipment in accordance with NFPA 101 and NFPA 70 (2011) based on the following:

1. Panel A electrical panel in Main Electrical Room does not have a breaker list.
2. Open electrical equipment in multiple areas.

NFPA 70 408.4 Field Identification Required. (A) Circuit Directory or Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard, and located at each switch or circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions of occupancy.

NFPA 70 110.27 Guarding of Live Parts. (A) Live Parts Guarded Against Accidental Contact. Except as elsewhere required or permitted by this Code, live parts of electrical equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Facility CEO and Director of Maintenance during the exit conference.

During the survey, it was determined that the facility failed to meet operational requirements in accordance with NFPA 101, NFPA 80 (2010) and NFPA 105 (2010). This was evidenced by:

1. Fire and fire/smoke damper access points were not labeled.

NFPA 80 19.2.3.2 The damper access panel shall be labeled with the words "Fire Damper" in letters not less than 1 in. (25 mm) in height.
-NFPA 105 6.3.2.2 A smoke damper access panel shall be labeled with the words "Smoke Damper" in letters not less than 1 in. (25.4 mm) in height. External insulation shall not conceal any access panel unless there is a label attached to the insulation\clearly indicating the exact location of the access panel and the insulation is installed for ease of removal or ease of removal with the access panel.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Facility CEO and Director of Maintenance during the exit conference.

During the survey, it was determined that the facility failed to meet the operating features requirements in accordance with NFPA 101 (2012). This was evidenced by:

1. Fire drills were not at varied times (1st Shift during 1st and 3rd Quarters)
2. Missing fire drills for 2nd Shift/2nd and 4th Quarters.

NFPA 101 19.7.1.6 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.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Facility CEO and Director of Maintenance during the exit conference.

During the survey, it was determined that the facility failed to meet the operating procedures requirements in accordance with NFPA 101. This was evidenced by:

1. Facility-wide no smoking policy was violated. Multiple smoking material disposal containers were found around site.

NFPA 101 19.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 19.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Facility CEO and Director of Maintenance during the exit conference.

During the survey, it was determined that the facility failed to meet operational requirements in accordance with NFPA 101, NFPA 110 (2010) and NFPA 99 (2012). This was evidenced by:

1. Missing annual fuel quality report for diesel generator.
2. Weekly visual inspection reports for generator do not include all required data.
3. Monthly inspection/testing/mainteance reports for generator do not include all required data.
4. Missing 36 month/4-hour Level 1 generator inspection/testing/mainteance report.

NFPA 110 8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards.

NFPA 110 8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

NFPA 110 8.4.2* Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperaturesas recommended by the manufacturer
(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating
-NPFA 99 6.6.3.1.2 The life safety branch shall be so arranged that, in the event of failure of the normal power source, the alternate source of power shall be automatically connected to the load within 10 seconds.

NFPA 110 8.4.9* Level 1 EPSS shall be tested at least once within every 36 months.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Facility CEO and Director of Maintenance during the exit conference.

During the survey, it was determined that the facility failed to meet operational requirements in accordance with NFPA 101 and NFPA 99 (2012). This was evidenced by:

1. Missing annual inspection/testing/maintance reports for electrical outlets tied to the life safety branch of the emergency power system. Current outlets are not "hospital grade".

NFPA 99 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. 6.3.4.1.4 The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Facility CEO and Director of Maintenance during the exit conference.

During the survey, it was determined that the facility failed to meet operational requirements in accordance with NFPA 101 and NFPA 99 (2012). This was evidenced by:

1. Full and empty oyxgen cylinders were not clearly seperated in the outside storage area.

NFPA 99 11.6.5.1 Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier. 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. 11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner.

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all affected smoke compartments. Deficient items were discussed with the Facility CEO and Director of Maintenance during the exit conference.