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The facility failed to ensure the fire resistance rating of occupancy separation walls. 19.1.3.5, 8.2.1.3

Observation determined there were unsealed openings around an electrical conduit penetration in the two-hour fire resistant rated occupancy separation wall between the hospital and the attached Ambulance Garage.

Failure to ensure the fire resistance rating of occupancy separation walls as required increases the risk of death or injury due to fire.

This deficiency affected one (1) of two (2) two-hour fire resistant rated occupancy separation walls in the facility.

The facility failed to ensure exit access was readily accessible at all times.

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 following corridor doors opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened.

1) The corridor door to the East Wing Data Room.
2) The corridor door to the South Wing Storage Room.

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

The deficiency affected two (2) of numerous corridor doors in the means of egress throughout the facility.

The facility failed to ensure the illumination of the means of egress was continuously in operation or capable of automatic operation without manual intervention.

Observation determined the lights in the north stairway from the basement to the exit were controlled by a switch.

Failure to ensure illumination in accordance with Chapter 7 throughout the means of egress increases the risk of injury or death due to fire.

This deficiency affected one (1) of four (4) exit stairways from the basement.

The facility failed to ensure emergency lighting of at least 1 1/2-hour duration.

1) A functional test must be conducted on every required emergency lighting system at 30-day intervals for a minimum of 30 seconds. An annual test must be conducted for 1 1/2-hour duration. Written records of testing must be kept by the owner for inspection by the authority having jurisdiction. 7.9.3

Review of records indicated the facility failed to conduct monthly 30-second and annual 1 1/2-hour tests on the emergency battery pack light in the Operating Room.

This deficiency affected one (1) of one (1) battery pack emergency lights in the building.

2) The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access.

Observation determined the location of the emergency power transfer switch located in the basement Boiler Room was not provided with battery powered emergency lighting as required.

Ref: 2012 NFPA 101 Section 19.2.9.1, 7.9.2.4; 2010 NFPA 110 Section 7.3.1

This deficiency affected emergency power equipment that serves the entire facility.

Failure to provide emergency lighting as required increases the risk of death or injury due to fire.

A door in a stair enclosure shall be self-closing and shall normally be kept in the closed position, unless otherwise permitted by 19.3.1.8. 19.3.1.7

The facility failed to ensure doors in a stair enclosure were self-closing.

Observation determined the doors to the stairways in the South Wing and the East Wing near the Nurses Station on the first floor failed to self-close and latch into the door frame.

Failure to ensure stairway doors self-close and latch into the door frame increases the risk of injury or death due to fire.

This deficiency affected two (2) of four (4) stairways connecting the first floor and the basement.

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 doors.

Observation determined the corridor door to Storage Room BUH053 in the basement was not equipped with a self-closing device.

Failure to ensure doors to hazardous areas are equipped with a self-closing device increases the risk of injury or death due to fire.

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

The facility failed to install alcohol based hand rub dispensers in accordance with 8.7.3.1.

Observation determined an alcohol based hand rub dispenser in the Staff Entrance was installed directly above a wall mounted electric heater.

Failure to install alcohol based hand rub dispensers in accordance with 8.7.3.1 increases the risk of injury or death due to fire.

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

The power source of non-power-limited fire alarm circuits shall comply with Chapters 1 through 4, and the output voltage shall be not more than 600 volts, nominal. The fire alarm circuit disconnect shall be permitted to be secured in the "on" position. NFPA 70, National Electrical Code. 760.41(A)

The branch circuit supplying the fire alarm equipment(s) shall supply no other loads. The location of the branch-circuit overcurrent protective device shall be permanently identified at the fire alarm control unit. The circuit disconnecting means shall have red identification, shall be accessible only to qualified personnel, and shall be identified as "FIRE ALARM CIRCUIT." The red identification shall not damage the overcurrent protective devices or obscure the manufacturer's markings. NFPA 70 760.41(B)

The facility failed to ensure the fire alarm system was in compliance with NFPA 70.

Observation determined the electrical circuit breaker providing power to the fire alarm system was not secured in the "on" position.

Failure to secure the electrical circuit breaker for the fire alarm system in the "on" position increases the risk of injury or death due to fire.

This deficiency affected the entire facility. The fire alarm system serves the entire building.

The facility failed to ensure detection devices of the fire alarm system were operational.

On 01/18/2017, record review determined the fire alarm system was inspected and tested by an outside company on 12/20/2016. Documentation determined three (3) of twenty-three (23) heat detectors throughout the facility failed when tested. Interview of staff determined the heat detectors had not been repaired or replaced.

Failure to ensure fire alarm system detection devices were operational increases the risk of injury or death due to fire.

This deficiency affected three (3) of twenty-three (23) heat detectors in the facility. The fire alarm system serves the entire facility.

The facility failed to ensure notification devices of the fire alarm system were operational.

On 01/18/2017, record review determined the fire alarm system was inspected and tested by an outside company on 12/20/2016. Documentation determined the audible alarm in the Lobby failed when tested. Interview of staff determined the audible alarm had not been repaired or replaced.

Failure to ensure fire alarm system audible devices are operational increases the risk of injury or death due to fire.

This deficiency affected one (1) of numerous audible devices in the facility. The fire alarm system serves the entire building.

Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 19.3.4.1

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with NFPA 72, National Fire Alarm Code.

Fire alarm system batteries shall be subjected to a load voltage test semiannually. NFPA 72, 14.4.2.2 item 5(e).

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. A load voltage test of the fire alarm system batteries was done during the annual inspection by an outside company on 12/20/2016. Records did not indicate any other load voltage test on the fire alarm system batteries in the past year.

Failure to test and maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected one (1) of two (2) required load voltage tests of the fire alarm batteries in the past year. The fire alarm system serves the entire facility.

Smoke detectors must not be located in a direct airflow nor closer than 3 ft. (1 m) 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.

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

Observation determined smoke detectors in the following locations were installed within 3 ft. of an air supply diffuser or return air opening:

1) The Lobby near the main entrance.
2) The Medical Records Room.
3) The South Wing exit corridor near the Sleep Study Room.

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

This deficiency affected three (3) of forty-nine (49) smoke detectors in the facility. The smoke detection system serves the entire facility.

Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. 19.7.6, 4.6.12, NFPA 25

A main drain test shall be conducted annually at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves. In systems where the sole water supply is through a backflow preventer and/or pressure reducing valves, the main drain test of at least one system downstream of the device shall be conducted on a quarterly basis. NFPA 25, 13.2.5, 13.2.5.1

All backflow preventers installed in fire protection system piping shall be tested annually by conducting a forward flow test of the system at the designed flow rate, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer. NFPA 25, 13.6.2.1

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25.

Record review determined:

1) Quarterly flow tests of the automatic sprinkler system were not completed as required. Records did not indicate a flow test was done during the first, second, and fourth quarters of 2016.

2) No annual back flow preventer test was conducted in the past twelve months.

Failure to inspect, test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

The deficiency affected the complete automatic sprinkler system, which serves the entire facility.

Fire extinguishers shall be manually inspected when initially placed in service and thereafter either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals. 19.3.5.12, 9.7.4.1, NFPA 10 7.2.1.1, 7.2.1.2

The facility failed to inspect portable fire extinguishers in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

Observation determined:

1) The inspection tag on the portable fire extinguisher in the Soiled Linen Room in the North Wing had not been initialed to indicate a monthly inspection during December 2016.

2) The inspection tag on the portable fire extinguisher located in the exit corridor near the Family Room on the first floor had not been initialed to indicate a monthly inspection during December 2016.

Failure to ensure portable fire extinguishers comply with NFPA 10 increases the risk of death or injury due to fire.

This deficiency affected two (2) of numerous fire extinguishers throughout the facility.

Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. 19.3.6.3.5

The facility failed to ensure corridor doors automatically latched into their frames and resisted the passage of smoke.

Observation determined:

1) The corridor door to the Staff Breakroom on the first floor did not latch into the door frame.
2) The corridor doors in the basement to the Warehouse Storage Room, the Cardiac and Pulmonary Room, Meeting Room BUH008, and the Conference Room were double sets of doors. The second leaf of each set of doors was equipped with a manual action lever to latch the door into the door frame.


Failure to ensure corridor doors automatically latch properly increases the risk of death or injury due to fire.

The deficiency affected four (4) of numerous corridor doors in the facility.

Drills shall be conducted quarterly on each shift to familiarize facility personnel with the signals and emergency action required under varied conditions. 19.7.1.6

The facility failed to conduct fire drills as required.

Fire drill records review determined no fire drills were conducted on the First Shift during the first and third quarter of 2016. The facility operates two shifts per day.

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

The deficiency affected two (2) of eight (8) drills in the past year.

All Level 1 and Level 2 installations of an emergency generator shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.

Observation determined there was no remote stop switch for the generator located external to the weatherproof enclosure. The generator was located outside the building.

Failure to ensure the emergency generator is in compliance with NFPA 110, Standard for Emergency and Standby Power Systems, increases the risk of death or injury due to fire.

The deficiency affected one (1) of one (1) emergency generator for the hospital.

Ref: 2012 NFPA 101 Section 19.2.9.1, 7.9.2.4, 2010 NFPA 110 Section 5.6.5.2(u).