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Based on observation and staff interview the facility failed to maintain fire rated construction of separated occupancies in accordance with NFPA 101 2012 Edition Sections 19.1.3 through 19.1.3.3, and 8.2.1 through 8.2.1.3. This deficient practice had the potential to affect all patients who reside within the hospital.

Findings include:

Observations during the tour of the facility with the Director of Maintenance (DM) on 01/08/24 between 8:30 A.M. and 3:00 P.M. identified fire separations not maintained. The second floor was currently under active construction, however, pipe chases and areas around electrical conduits discovered in vertical and horizontal fire barriers were not sealed. Further observation identified no active construction was not being performed at the time survey.

Interview with the DM verified the finding at the time of observation.


19.1.3 Multiple Occupancies.
19.1.3.1 Multiple occupancies shall be in accordance with 6.1.14.
19.1.3.2 Sections of health care facilities shall be permitted to be classified as other occupancies in accordance with the separated occupancies provisions of 6.1.14.4 and either 19.1.3.3 or 19.1.3.4.
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.

8.2 Construction and Compartmentation.
8.2.1 Construction.
8.2.1.1 Buildings or structures occupied or used in accordance with the individual occupancy chapters, Chapters 11 through 43,
shall meet the minimum construction requirements of those chapters.
8.2.1.2* NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification.
8.2.1.3 Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on one of the following:
(1) Separate buildings, if a 2-hour or greater vertically aligned fire barrier wall in accordance with NFPA 221, Standard for High Challenge FireWalls, FireWalls, and Fire BarrierWalls, exists between the portions of the building
(2) Separate buildings, if provided with previously approved separations
(3) Least fire-resistive construction type of the connected portions, if separation as specified in 8.2.1.3(1) or (2) is not provided

Based on observation, record review, and staff interview, the facility failed to ensure Fire Watch Policy was developed and being conducted accordance with NFPA 101 - 2012 Edition 19.3.5.1; 9.7.5, and NFPA 25 - 2010 Edition 15.5. This deficient practice had the potential to affect all patients who reside within the hospital.

Findings include:

Record review on 01/08/25 in the facility between 8:20 A.M. and 11:50 A.M. it was noted that the Fire Watch Policy did not address the proper procedure for assigning individuals to conduct a fire watch. The Fire Watch is to be a continuous surveillance of the area/s of the facility in which the sprinkler system is out of service. The second-floor sprinkler system was not intact and under renovation. No fire watch was being conducted throughout the affected area of the facility. Record review of the previous fire watch logs noted the record consisted of a single sheet and lacked the time, location, and staff name information when the tours were performed.. No additional documentation was provided at the time of survey to validate the fire watch procedure was performed in accordance to the applicable code.

Interview with the Director of Maintenance verified the finding at the time of review.

NFPA 101 - 2012 Edition
19.3.5 Extinguishment Requirements.
19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.
19.3.5.2 High-rise buildings shall comply with 19.4.2.
19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.
19.3.5.4* The sprinkler system required by 19.3.5.1 or 19.3.5.3 shall be installed in accordance with 9.7.1.1(1).
19.3.5.5 In Type I and Type II construction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered. Reference- Sprinkler

9.7.5 Maintenance and Testing. 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.

NFPA 25 - 2010 Edition
15.5* Preplanned Impairment Programs.
15.5.1 All preplanned impairments shall be authorized by the impairment coordinator.
15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b)*An approved fire watch
(c)*Establishment of a temporary water supply
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.

Based on observations and interviews the facility failed to ensure that all smoke barriers were able to resist the passage of smoke in accordance with the LSC, 2012 Edition 19.3.7.3 and 8.5.6.2. This deficient practice had the potential to affect all patients who reside within the hospital.

Findings include:

Observations during tour of the with the Director of Maintenance (DM) at 10:10 A.M. on 01/08/25 revealed smoke barriers not maintained in the second floor construction area. Pipe chases between floors that did not have active work being performed were not sealed between the occupied section and the area under construction.

Interview with the DM verified the findings at the time of observation.

NFPA 101-2012 Edition, Section 19.3.7.3 states, Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1.2-hour fire resistance rating, unless otherwise permitted by one of the
following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).
(b) Not less than two separate smoke compartments shall be provided on each floor.
(2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating,
and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

NFPA 101-2012 Edition, Section 8.5.6.2 states, 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.