HospitalInspections.org

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls. This could result in the spread of smoke in the event of a fire and affected 2 of 6 smoke compartments.


Findings:

During a tour of the facility and interview with PO, the walls and ceilings, were observed.

1. On 8/18/22 at 11:36 a.m., there was a penetration observed between Room 320A (Men's bathroom) and Room 322 (Women's bathroom). The penetration measured approximately one inch in diameter. Upon interview, PO1 confirmed the finding and stated that he was not aware of the penetration.


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2. On 8/18/22 at 2:37 p.m., an approximately two inch by two inch penetration was observed in the Northwest wall of Operating Room 1, near the nitrogen control valve. The penetration had a data cable running through it. Upon interview, PO1 and PO2 confirmed the finding.

Based on observation and interview, the facility failed to maintain the doors with self-closing devices. This was evidenced by a door that was obstructed from closing by a rubber wedge and a magnetic release device that failed to hold the door open. This affected 1 of 6 smoke compartments and could result in the spread of fire or smoke in the event of a fire.


Findings:

During a tour of the facility and interview with PO, the doors, were observed.

On 8/18/22 at 11:19 a.m., the door to the storage room in the operating room area, was observed held open by a wedge that had been placed under the door leaf. The door was equipped with a self-closing device and a magnetic hold open device that was tied into the fire alarm system. When the wedge was removed, the magnetic hold open device failed to hold the door in the open position. Upon interview, PO2 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the emergency exit signs. This was evidenced by the failure of exit signs to illuminate with testing, and to perform annual 90-minute testing for the battery back-up exit signs. This affected 6 of 6 smoke compartments and could result in a delay in evacuation in the event of a power outage.

NFPA 101, Life Safety Code, 2012 Edition
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4.
7.10.9 Testing and Maintenance.
7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance with 7.9.3.1.3.
7.10.9.2 Testing. Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with
7.9.3.
7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1,
7.9.3.1.2, or 7.9.3.1.3.
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 1 1/2 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).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority havingjurisdiction.


Findings:

During a facility tour, record review, and interview with PO, the exit signs were observed, and records were requested.

1. On 8/19/22 at 11:50 a.m., documentation titled "Exit Sign Testing" dated 2021-2022, indicated that the approximately 37 battery back-up exit signs, observed throughout the facility's corridors and common areas, were not tested for 90 minutes consecutively for the past 12 months from 2021-2022.
Upon interview, PO2 confirmed the finding, and said that they were tested monthly for 30 seconds.


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2. On 8/18/22 at 11:42 a.m., the exit sign in the Courtyard across the Administration office was not illuminated. Upon interview, PO1 confirmed that the exit sign was not illuminating.

Based on observation and interview, the facility failed to maintain the hazardous area enclosures. This was evidenced by a set of double doors with kick down hold open devices installed that prevented doors from closing. This affected 1 of 6 smoke compartments and could result in the spread of smoke and fire.


Findings:

During a tour of the facility and interview with PO, the hazardous enclosure areas, were observed.

On 8/18/22 at 2:31 p.m., the double doors to the room labeled Post Anesthesia Care Unit in the operating room area, was observed held open. Both door leafs had kickstand type hold open devices installed which were holding both doors in the fully opened position. The operating room had been decommissioned and the room was converted to a storage occupancy. The room was approximately 450 square feet and stored cardboard boxes and hospital beds. Upon interview, PO1 and PO2 confirmed the finding.

Based on observation and interview, the facility failed to maintain the cooking facilities. This was evidenced by the obstruction of fire-extinguishing equipment and by a detached nozzle cap on the kitchen suppression system. This affected 2 of 6 smoke compartments. This could result in staff's inability to readily access the extinguisher and a malfunctioning suppression system in the event of a fire.

NFPA 101 Life Safety Code, 2012 Edition
19.3.2.5 Cooking Facilities.
19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4.

19.5 Building Services
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.

9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011, Edition
10.1.1 Fire-extinguishing equipment for the protection of grease removal devices, hood exhaust plenums, and exhaust duct systems shall be provided.
10.1.2* Cooking equipment that produces grease-laden vapors and that might be a source of ignition of grease in the hood, grease removal device, or duct shall be protected by fire-extinguishing equipment.
10.2.1 Fire-extinguishing equipment shall include both automatic fire-extinguishing systems as primary protection and portable fire extinguishers as secondary backup.

10.2.6 Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable:
(1) NFPA 12
(2) NFPA 13
(3) NFPA 17
(4) NFPA 17A

NFPA 17A, Standard for Wet Chemical Extinguishing Systems, 2009 edition
4.3.1.5 All discharge nozzles shall be provided with caps or other suitable devices to prevent the entrance of grease vapors, moisture, or other foreign materials into the piping.


Findings:

During a tour of the facility and interview with PO, the cooking facilities were observed, and staff was interviewed.

1. On 8/18/22 at 11:03 a.m., in the Kitchen, the fire-extinguishing equipment for the suppression system was obstructed from immediate access by 12 boxes in various sizes and three cases of bottled water. Upon interview, PO1 confirmed the finding.

2. On 8/18/22 at 1:08 p.m., the kitchen hood suppression system, was observed with two discharge nozzles. One discharge nozzle had a cap that was not attached to the nozzle. Upon interview, PO1 confirmed the finding.

Based on observation and interview, the facility failed to maintain the fire alarm system. This was evidenced by a manual pull station that was obstructed and not accessible. This could lead to the delay of notification in the event of an emergency. This affected 1 of 6 smoke compartments.


Findings:

During a tour of the facility and interview with PO, the manual pull stations were observed.

On 8/18/22 at 11:03 a.m., the manual pull station in the kitchen was obstructed by 12 boxes in various sizes, and three cases of bottled water. Upon interview, PO1 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the fire alarm system (FAS). This was evidenced by the failure to perform a semi-annual inspection. This affected 6 of 6 smoke compartments and could result in a system malfunction or delay in notification in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1* General.
9.6.1.5* 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.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition.
Chapter 14 Inspection, Testing, and Maintenance
14.1 Application.
14.1.1 The inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter.
14.3 Inspection.
14.3.1* Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction.
14.3.2 Devices or equipment that is inaccessible for safety considerations (e.g., continuous process operations, energized electrical equipment, radiation, and excessive height) shall be permitted to be inspected during scheduled shutdowns if approved by the authority having jurisdiction.
14.3.4 The visual inspection shall be made to ensure that there are no changes that affect equipment performance.

Table 14.3.1 Visual Inspection Frequencies-semiannually
3. Batteries
4. Transient suppressors
5. Fire alarm control unit trouble signals
7. In- building fire emergency voice/alarm communications equipment
8. Remote annunciators
9. Initiating devices
10. Guard's tour equipment
11. Combination systems (a) Fire extinguisher electronic monitoring device/systems
(b) Carbon monoxide detectors/systems
12. Interface equipment
13. Alarm notification appliances
14. Exit marking audible notification appliances
15. Supervising station alarm systems-transmitters
16. Special procedures
17. Supervising station alarm systems-receivers
18. Public emergency alarm reporting system transmission equipment
20. Mass notification system, non-supervised systems installed prior to adoption of this edition

14.6.2 Maintenance, Inspection, and Testing Records.
14.6.2.1 Records shall be retained until the next test and for 1 year thereafter.
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) Tests 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)

Findings:

During a facility tour, document review, and interview with PO, the FAS was observed, and records were requested.

On 8/19/22 at 12:04 p.m., the facility was observed with an automatic FAS. The current Annual Fire Alarm Inspection/Testing Report was dated 12/6/21. No post-semi-annual visual inspection with panel battery testing, was available for review. Upon interview, PO1, and PO2 confirmed that the FAS is inspected and tested on an annual basis.

Based on observation, document review, and interview, the facility failed to maintain the integrity of the wet-automatic fire sprinkler system. This was evidenced by the failure to correct listed deficiencies on an annual inspection, perform routine quarterly inspections, maintain minimum clearance to storage, an obstructed Inspector's Test Valve (ITV), and a damaged Post Indicator Valve (PIV). This affected 6 of 6 smoke compartments and could result in the ineffective operation of the automatic fire sprinkler system in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.5 Extinguishment Requirements.
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.

9.7 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
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 13, Standard for the Installation of Sprinkler System. 2010 Edition
8.6.6* Clearance to Storage (Standard Pendent and Upright Spray Sprinklers).
8.6.6.1 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition.
4.1.1* Responsibility for Inspection, Testing, Maintenance, and Impairment. The property owner or designated representative shall be responsible for properly maintaining a waterbased fire protection system.
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.

4.3 Records
4.3.1* Records shall be made inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.

Chapter 5 Sprinkler Systems.
5.1.1 Minimum Requirements.
5.1.1.1 This chapter shall provide the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.

5.2.1 Sprinklers.
5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following
shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)*Loading
(6) Painting unless painted by the sprinkler manufacturer
5.2.5 Waterflow Alarm and Supervisory Devices. Waterflow alarms and supervisory alarm devices shall be inspected quarterly to verify that they are free of physical damage.
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.

5.3.3 Waterflow Alarm Devices.
5.3.3.1 Mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly.

Chapter 13 Valves, Valve Components, and Trim
13.1* General.
13.1.1 Minimum Requirements.
13.1.1.1 This chapter shall provide the minimum requirements for the routine inspection, testing, and maintenance of valves, valve components, and trim.

13.3.2 Inspection.
13.3.2.1 All valves shall be inspected weekly.
13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPAstandards shall be permitted to be inspected monthly.
13.3.2.2* The valve inspection shall verify that the valves are in the following condition:
(3) Accessible

13.4 System Valves.
13.4.1 Inspection of Alarm Valves. Alarm valves shall be inspected as described in 13.4.1.1 and 13.4.1.2.
13.4.1.1* Alarm valves and system riser check valves shall be externally inspected monthly and shall verify the following:
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.

Findings:

During a facility tour, document review, and interview with PO, and AS, the automatic fire sprinkler system was observed.

1. On 8/19/22 at 12:20 p.m., the facility, was observed fully sprinklered with a wet automatic fire sprinkler system. Documentation titled "Annual Report" dated 8/5/21, was reviewed. The report was marked "failed" due to the following deficiencies: 1) Painted sprinkler heads 2) incorrect sprinkler heads 3) valves not maintained. No follow-up documentation for correction of listed deficiencies was available.
Upon interview, AS1, PO1, and PO2 confirmed the findings, and PO1 said that it had been difficult to get a vendor to the facility for repair due to COVID.

2. On 8/19/22 at 12:45 p.m., no quarterly sprinkler inspection records were available for the first quarter (January, February, March), and second quarter (April, May, June) of 2022, and fourth quarter(October, November, December) of 2021. Upon interview, PO1 confirmed the findings after review of the records.


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3. On 8/18/22 at 10:44 a.m., the receiving area by the Materials Management Room 117, was observed. There were six boxes stored approximately five inches from the sprinkler deflector. Upon interview, PO1 confirmed the finding.


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4. On 8/18/22 at 3:13 p.m., the annex building, was observed. The building was fully sprinklered and was equipped with an Inspectors Test Valve (ITV). The ITV was located on the north wall of the annex and was obstructed by cardboard boxes and medical equipment storage. Upon interview, PO1 and PO2 confirmed the finding.

5. On 8/18/22 at 3:19 p.m., the Post Indicator Valve outside of the Fire Alarm Control Panel and Fire Sprinkler Riser room, was observed. Both windows on the valve that allow the valve position to be viewed where obscured by haze and corrosion on the glass and the valve position could not be seen. Upon interview, PO1 and PO2 confirmed the finding.

Based on observation and interview, the facility failed to maintain their portable fire extinguishers. This was evidenced by fire extinguishers that were obstructed from immediate access, not inspected at a minimum of 30-day intervals. This affected 2 of 6 smoke compartments. This could result in staff's inability to readily access the fire extinguisher in the event of a fire and a delayed notification of malfunctioning portable fire extinguisher.

NFPA 101, Life Safety Code, 2012 Edition
19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.

9.7.4 Manual Extinguishing Equipment.
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition
6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view.

7.2 Inspection.
7.2.1 Frequency.
7.2.1.1* Fire extinguishers shall be manually inspected when initially placed in service.
7.2.1.2* Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals.

7.2.4.3 Where at least monthly manual inspections are conducted, the date the manual inspection was performed and the initials of the person performing the inspection shall be recorded.

Findings:

During a tour of the facility and interview with PO, the fire extinguishers were observed.

1. On 8/18/22 at 10:48 a.m., the fire extinguisher in the corridor by the Materials Management office was obstructed from immediate access by a medical cart. The medical cart was placed in front of the fire extinguisher. Upon interview, PO1 confirmed the finding.

2. On 8/18/22 at 10:57 a.m., the fire extinguisher in the Pharmacy, Room 110 was not inspected during the month of July 2022. Upon interview, PO1 confirmed the finding.

3. On 8/18/22 at 11:13 a.m., the fire extinguisher in the cafeteria was obstructed from immediate access by a table. The table was placed in front of the fire extinguisher. Upon interview, PO1 confirmed the finding.
4. On 8/18/22 at 11:48 a.m., the fire extinguisher in the IT Room across Room 112 was not inspected during the months of April, May, June, and July of 2022. Upon interview, PO1 confirmed the finding.


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5. On 8/18/22 at 11:40 a.m., an ABC fire extinguisher in the staff room next to the Director of Nursing's Office was observed obstructed by a five-gallon water cooler. The water cooler was directly in front of the fire extinguisher obstructing it from view. Upon interview, PO2 confirmed the finding.

6. On 8/18/22 at 3:04 p.m., three ABC fire extinguishers were observed on a metal wire shelf in the mechanical room. The fire extinguishers were not supported and free standing on the shelf. The annual inspection on the extinguishers was dated 3/3/2021. Upon interview, PO1 and PO2 confirmed the finding.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by corridor doors that failed to latch, a corridor door obstructed, and corridor doors with penetrations. This affected 2 of 6 smoke compartments and could result in the inability to contain smoke and/or fire to a room.


Findings:

During a tour of the facility and interview with AS and PO, the corridor doors were observed.

1. On 8/18/22 at 10:39 a.m., the corridor door to the Room 118, Auxiliary Services was equipped with a self-closing device. The door failed to latch when allowed to self-close. The door was test three times and failed. Upon interview, PO1 confirmed the finding.

2. On 8/18/22 at 11:02 a.m., the door to the Janitorial Room in the kitchen was equipped with a self-closing device. The door failed to latch when allowed to self-close. Upon interview, PO1 confirmed the finding.

3. On 8/18/22 at 11:03 a.m., the door to the Pantry room in the kitchen was equipped with a self-closing device. The door failed to latch when allowed to self-close. Upon interview, PO1 confirmed the finding.

4. On 8/18/22 at 11:44 a.m., the corridor door to Room 309B by a Doctor's lounge had two penetrations above a key punch lock measuring approximately 3/8 inch in diameter. Upon interview, PO1 confirmed the finding and stated from an old lock that was replaced.

5. On 8/18/22 at 11:48 a.m., the corridor door to the IT Room across Room 112 was equipped with a self-closing device. A tape over the strike plate obstructed the door from latching. Upon interview, AS1 confirmed the finding.

6. On 8/18/22 at 12:05 p.m., the corridor double door to Room 294 was equipped with a self-closing device. The right door failed to latch when allowed to self-close. Upon interview, PO1 confirmed the finding.

7. On 8/18/22 at 12:08 p.m., the corridor door to Room 309A was observed with seven penetrations. Six penetrations measured approximately 3/8 inch in diameter and one penetration measured approximately 1 ½-inch in diameter. Upon interview, PO1 confirmed the finding and stated that the holes were from an old doorknob that was replaced.


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8. On 8/18/22 at 10:36 a.m., the corridor door labeled 299 to the Outpatient Services reception and waiting area was observed with plastic in the strike plate preventing the door from latching. The door was equipped with a self-closing device and tested three times. Upon interview, PO2 confirmed the finding.

9. On 8/18/22 at 10:44 a.m., the double corridor door labeled 294 to the emergency room was tested and the right-side door leaf failed to latch. Both doors were equipped with self-closing devices and tested three times. the emergency room was decommissioned and had been converted to a Dialysis room. Upon interview, PO2 confirmed the finding.

10. On 8/18/22 at 11:14 a.m., the double corridor door labeled 261 B to the operating room was tested. The door was equipped with a magnetic hold open device, a self-closing device and door coordinator hardware. The door coordinator hardware was not functioning properly and when the door was tested, the coordinator hardware obstructed the right-side door leaf from closing completely, leaving an approximate six inch gap between the left and right door leaf. The double doors were tested three times. Upon interview, PO2 confirmed the finding.

11. On 8/18/22 at 11:59 a.m., the corridor door labeled 192 to the Nourishment Room did not latch when tested. The door was equipped with a self-closing device and was tested three times. Upon interview, PO2 confirmed the finding.

12. On 8/18/22 at 12:01 p.m., the corridor door to Patient Room 125 failed to latch when tested. Upon interview, PO2 confirmed the finding.

Based on document review and interview, the facility failed to conduct fire drills one per shift per quarter. This was evidenced by the absence of documentation for the performance of three of eight required fire drills. This affected 6 of 6 smoke compartments and could result in staff being untrained and unaware of shift-specific roles and responsibilities during an emergency.

Findings:

During document review and interview with PO, the fire drill records were requested.

On 8/19/22 at 10:50 a.m., no documentation was available for the P.M., shift drill, first quarter (January, February, March) 2022, P.M. Second quarter (April, May, June) 2022, or for the P.M. fourth quarter (October, November, December) 2021 Upon interview, PO2 confirmed that the facility had two, 12-hour nursing shifts, and that fire drills were performed on the A.M., shift for all nursing staff. PO1, and PO2 confirmed the findings after record review, and said that they were not aware that the drills had to be shift specific and had only started implementing them separately on each shift in the third quarter.

Based on observation, document review, and interview, the facility failed to maintain the fire rated door assemblies in access corridors. This was evidenced by the absence of an annual inspection and testing certification. This affected 6 of 6 smoke compartments and could result in the unsafe operation of fire doors.

NFPA 101. Life Safety Code, 2012 Edition
19.1.1.4.1.1 Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire door assemblies. (See also Section 8.3.)

8.3.3 Fire Doors and Windows.
8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protective's, except as otherwise specified in this Code.

NFPA 80, Standard for Fire Doors and Other Opening Protective's, 2010 edition.
Chapter 5 Care and Maintenance
5.1* General.
5.1.1 Application.
5.1.1.1 This chapter shall cover the care and maintenance of fire doors and fire windows.

5.2* Inspections.
5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall
be signed and kept for inspection by the AHJ.
5.2.3 Functional Testing.
5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.
5.2.3.2 Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting.
5.2.4 Swinging Doors with Builders Hardware or Fire Door Hardware.
5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.
5.2.4.2 As a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.
5.2.14 Maintenance of Closing Mechanisms
5.2.14.1 Self-closing devices shall be kept in working condition at all times.

Chapter 13 Service Counter Fire Doors
13.4 Automatic Closing.
13.4.1 All service counter fire doors shall be equipped to close automatically in the event of fire.
13.4.2 A service counter fire door of the rolling type shall be automatic closing so that, upon activation or release of a fusible link or detector, the door shall close.


Findings:

During a facility tour, document review, and interview with PO, the fire rated doors, were observed, and inspection records were requested.

On 8/19/22 at 12:30 p.m to 12:50 p.m.., the facility was observed with 60-minute swinging and rolling fire doors located in the access corridors in all smoke compartments. No certification for (NFPA 80 Standard for Fire Doors) annual testing and inspection was available for review when requested. Upon interview, PO1 confirmed the finding, and said that the doors were in the process of being inspected today (8/19/22) by a vendor to NFPA 80 requirements.

Based on observation and interview, the facility failed to follow the manufacturer's directions on a portable space heater. This was evidenced by a space heater placed too close to flammable material, plugged into a power strip and plugged in while not in use. This affected 1 of 6 smoke compartments and could result in causing a fire.


Findings:

During a tour of the facility and interview with AS, and PO, the Director of Nursing's desk, was observed.

On 8/18/22 at 9:32 a.m., a portable space heater was observed plugged into a power strip and not in use at the Director of Nursing's desk. The portable space heater was on the floor, with the back of the heater approximately one inch away from the wall and six inches away from sheets of paper and a backpack on the ground. According to the manufacturer's instructions on a caution label on the portable space heater, the heater should be unplugged while not in use, plugged directly into a wall outlet and at least three feet away from combustible materials on all sides. Upon interview, PO2 and AS1 confirmed the finding.

Based on observation and interview, the facility failed to maintain the vacuum and piped medical gas systems. This was evidenced by a medical gas master alarm panel obstructed by medical equipment. This affected 1 of 6 smoke compartments and could result in delayed access to the panel in the event of an emergency.

NFPA 99: Health Care Facilities Code, 2012 Edition
3.3.4.4 Master Alarm System. A warning system that monitors the operation and condition of the source of supply, the reserve source (if any), and the pressure in the main lines of each medical gas and vacuum piping system. (PIP)
5.1.9.2 * Master Alarms. A master alarm system shall be provided to monitor the operation and condition of the source of supply, the reserve source (if any), and the pressure in the main lines of each medical gas and vacuum piping system.
5.1.9.2.1 The master alarm system shall consist of two or more alarm panels located in at least two separate locations, as follows:
(2) In order to ensure continuous surveillance of the medical gas and vacuum systems while the facility is in operation, the second master alarm panel shall be located in an area of continuous observation (e.g., the telephone switchboard, security office, or other continuously staffed location).


Findings:

During a tour of the facility and interview with PO, the gas and vacuum piped medical gas system was observed.

On 8/18/22 at 2:34 p.m., the Medplus Total Alert master alarm panel, was observed in the operating room area across from Operating Room (OR2). Medical equipment was stored along the wall and directly in front of the panel, obstructing view and access to the panel. Upon interview, PO1 and PO2 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the emergency power supply system (EPSS). This was evidenced by the failure to conduct an annual 90-minute load bank test. This affected 6 of 6 smoke compartments and could result in a loss of power due to a generator malfunction during an emergency power outage.

NFPA 101 Life Safety Code, 2012 edition
19.5.1 Utilities, Utilities shall comply with the provisions of section 9.1
19.5.1.1 Utilities shall comply with the provisions of section 9.1
9.1.3.1 Emergency Generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition.
Chapter 8 Routine Maintenance and
Operational Testing
8.1* General.
8.1.1 The routine maintenance and operational testing program shall be based on all of the following:
(1) Manufacturer's recommendations
(2) Instruction manuals
(3) Minimum requirements of this chapter
(4) The authority having jurisdiction
8.3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established.
8.3.4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.
8.3.4.1 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

8.4 Operational Inspection and Testing.
8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.
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 temperatures as recommended by the manufacturer
(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating
8.4.2.1 The date and time of day for required testing shall be decided by the owner, based on facility operations.
8.4.2.2 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
8.4.2.3 Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available
EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.

Findings:

During a facility tour, document review, and interview with PO, the EPSS, was observed, and records were requested and reviewed.

On 8/19/22 at 12:36 p.m., the facility was observed with a 225-kilowatt diesel generator. Routine monthly 30-minute load documentation for the past 12 months did not indicate minimal exhaust temperature, or that 30 percent of the name plate kilowatt rating was achieved with the available load. No current annual 90-minute supplemental load bank test was available for review. The previous four-hour load bank was completed on 2/16/21. Upon interview, PO1 confirmed the findings after reviewing the records, and stated that an annual load test had not been completed after the last test was completed on 2/16/21.

Based on observation and interview, the facility failed to maintain the electrical system and its components. This was evidenced by obstructed electrical panels and by an electrical receptacle that was missing a faceplate. This affected 2 of 6 smoke compartments and could result in an increased risk of an electrical fire.

NFPA 101 Life Safety Code, 2012 edition
19.5.1 Utilities. Utilities shall comply with the provisions of section 9.1
9.1.2 Electrical Systems. 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.

NFPA 70 National Electrical Code, 2011 edition
110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.
(A) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26(A)(1), (A)(2), and (A)(3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26(A)(1) unless the requirements of 110.26(A)(1)(a), (A)(1)(b), or (A)(1)(c) are met. Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed.
(2) Width of Working Space. The width of the working space in front of the electrical equipment shall be the width of the equipment or 762 mm (30 in.), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

406.6 Receptacle Faceplates (Cover Plates). Receptacle faceplates shall be installed so as to completely cover the opening and seat against the mounting surface. Receptacle faceplates mounted inside a box having a recess-mounted receptacle shall effectively close the opening and seat against the mounting surface.


Findings:

During a tour of the facility and interview with PO, the electrical system and its components, were observed.

1. On 8/18/22 at 10:30 a.m., the electrical panels in the Telephone Room 121, were observed. The electrical panels were obstructed by a rolling cart stationed directly in front of the electrical panels. Upon interview, PO1 confirmed the finding.

2. On 8/18/22 at 11:38 a.m., the electrical outlet near a desk in Room 308, Medical Records office was missing a faceplate. Upon interview, PO1 confirmed the finding.

Based on observation and interview, the facility failed to maintain electrical safety. This was evidenced by the failure to prohibit the use of power strips and extension cords as substitutes for permanent fixed wiring. This could result in an increased risk of an electrical fire and or electrical shock. This affected 2 of 6 smoke compartments.

NFPA 101, Life Safety Code, 2012 Edition
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.

9.1.2 Electric Systems. 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.

NFPA 70, National Electrical Code, 2011 Edition
400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage


Findings:

During a tour of the facility and interview with PO, the electrical wiring and equipment, was observed.

1. On 8/18/22 at 10:44 a.m., the electrical wiring in Room 117, Materials Management, was observed. A microwave and a refrigerator were plugged into a power strip. Upon interview, PO1 confirmed the finding.

2. On 8/18/22 at 11:19 a.m., the electrical wiring in the Administration office, was observed. A microwave near a copier machine was plugged into a green extension cord. Upon interview, PO1 confirmed the finding.

3. On 8/18/22 at 11:23 a.m., in the Administration office, a yellow extension cord, was observed supplying power to a computer server machine in Room 320, by the Human Resource office. Upon interview, PO1 confirmed the finding.

4. On 8/18/22 at 11:31 a.m., a Dinamap Vital machine, water dispenser, printer and a name tag machine were plugged into a power strip across the Human Resource office. Upon interview, PO1 confirmed the finding.


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5. On 8/18/22 at 10:40 a.m., the three reception workstations in the Outpatient Services area, were observed with daisy chained power strips. The first workstation had a white power strip secured under the desk that was plugged into a wall outlet and was powering a second power strip that was secured under the desk of the third workstation. Both power strips were powering phone and computer equipment. Upon interview, PO2 confirmed the finding.

6. On 8/18/22 at 10:49 a.m., a portable LG brand air conditioner in the Laboratory, was observed plugged into an orange extension cord. The extension cord was plugged into a wall outlet labeled LEC1 42. Upon interview, PO2 confirmed the finding.

Based on observation and interview, the facility failed to maintain the oxygen cylinder storage. This was evidenced by free standing cylinders not secured, combustible materials being stored next to full oxygen cylinders and storage locations not secured against unauthorized entry. This affected the outdoor oxygen storage enclosure on the Northeast side of the facility, the oxygen storage enclosure in the annex building and the oxygen storage enclosure on the North side of the facility in the parking lot and could result oxygen cylinders falling over, increased fire risk and unauthorized access to the oxygen enclosure.

NFPA 99: Health Care Facilities Code, 2012 Edition
11.3 Cylinder and Container Storage Requirements.
11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
(1) Minimum distance of 6.1 m (20 ft)
(2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems
(3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/ 2 hour
11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures:
(1)Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device.
(2)Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them.
(3)Cylinders shall be protected from tampering by unauthorized individuals.
(4)Cylinders or cylinder valves shall not be repaired, painted, or altered.
(5)Safety relief devices in valves or cylinders shall not be tampered with.
(6)Valve outlets clogged with ice shall be thawed with warm - not boiling - water.
(7)A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device.
(8)Sparks and flame shall be kept away from cylinders.
(9)Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them.
(10)Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1.
(11)Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
(12)Cylinders shall not be supported by radiators, steam pipes, or heat ducts.

Findings:

During a tour of the facility and interview with PO, the oxygen storage enclosures were observed.

1. On 8/18/22 at 3:00 p.m., the oxygen storage enclosure on the Northeast side of the facility, was observed with seven free standing H size oxygen tanks that were not properly chained or supported. Upon interview, PO1 and PO2 confirmed the finding.

2. On 8/18/22 at 3:11 p.m., the oxygen storage area inside the annex building, was observed with a cardboard box and a plastic garbage bag stored directly next to the oxygen cylinders. The annex was fully sprinklered and contained approximately 29 H tanks and 28 E tanks. Upon interview, PO1 and PO2 confirmed the finding.

3. On 8/18/22 at 3:15 p.m., the outside bulk oxygen storage tank area on the north side of the facility, was observed surrounded by a fence. The fence had an approximately 20 inch opening between two of the fence panels that was not secured against unauthorized entry. Upon interview, PO1 and PO2 confirmed the finding.