HospitalInspections.org

Based on observation, interview and testing, the facility failed to ensure that means of egress were continuously maintained free of obstructions in case of emergency. This deficient practice affected one of six smoke compartments, its residents, staff and guests.

Findings include:

On 05/10/17, the left leaf of the exit door in the kitchen area was impeded as it was rubbing on the threshold. A door pressure gauge revealed the door took more than 30 foot-pounds of pressure to open when tested.

The Regional Director of Plant Operations acknowledged the deficiency at the time of discovery.

Based on observation and interview, the facility failed to ensure that emergency lighting would operate a minimum of 1 1/2 hours in the event normal lighting failed. This deficient practice affected one of six smoke compartments, its residents, staff and guests.

Findings include:

On 05/09/17, record review revealed 1 1/2 hour functional testing of emergency lighting was not conducted annually as required.

On 05/09/17 at 3:35 PM, the Maintenance Mechanic explained the annual testing of emergency lighting was not accomplished as required.

On 05/10/17, the Regional Director of Plant Operations acknowledged the deficiency.

Based on record review and interview, the facility failed to ensure fire alarm testing and maintenance documentation was readily available. This deficient practice affected six of six smoke compartments, their residents, staff and guests.

Findings include:

On 05/09/17, a request was made to review the fire alarm system testing and maintenance vendor reports. The records revealed the two-year smoke detector sensitivity report was not readily available.

On 05/10/17, the Regional Director of Plant Operations confirmed that the two-year sensitivity report was missing.

The Regional Director of Plant Operations and Chief Executive Officer acknowledged the deficiency during the exit interview.

Ref: NFPA 13
National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems, 2010 Edition

6.2.7 Escutcheons and Cover Plates.
6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler.

8.5.5 Obstructions to Sprinkler Discharge.
8.5.5.2* Obstructions to Sprinkler Discharge Pattern Development.
8.5.5.2.2 Sprinklers shall be positioned in accordance with the minimum distances and special requirements of Section 8.6 through Section 8.12 so that they are located sufficiently away from obstructions such as truss webs and chords, pipes, columns, and fixtures.

8.6.4.1 Distance Below Ceilings.
8.6.4.1.1 Unobstructed Construction.
8.6.4.1.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm) throughout the area of coverage of the sprinkler.


Ref: NFPA 25
National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition

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
5.2.1.1.3* Any sprinkler that has been installed in the incorrect orientation shall be replaced.
5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation.
5.2.1.1.5 Glass bulb sprinklers shall be replaced if the bulbs have emptied.


Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system. The facility was sprinklered throughout with the standard pendent type. The requirements of 8.6.4.1.1.1 shall not apply where ceiling type sprinklers (concealed, recessed, and flush types) have the operating element above the ceiling. This deficient practice affected six of six smoke compartments, their residents, staff and guests.

Findings include:

On 05/09/17 and 05/10/17, during a tour of the facility the following automatic fire sprinkler system concerns were observed.

1) Medical Records Office: Sprinkler was loaded with dust.

2) Environmental Services: Loose escutcheon exposing the annular space of the sprinkler pipe.

3) Women's Locker Room: Sprinkler was loaded with dust.

4) Dietary (Dry Storage): Loose escutcheon exposing the annular space of the sprinkler pipe.

5) Maintenance Office: Loose escutcheon exposing the annular space of the sprinkler pipe.

6) Kitchen:
a) Two sprinklers were loaded with dust.
b) Dry Storage: Loose escutcheon exposing the annular space of the sprinkler pipe.
c) Outside of walk-in refrigerator: One sprinkler was corroded.

7) Mirage Dining Room: One fire sprinkler deflector was measured to be 1/2 inch below its escutcheon.

8) Human Resources Office: Loose escutcheon exposing the annular space of the sprinkler pipe.

9) Director of Case Management Office: Sprinkler was loaded with dust.

10) Physical Therapy:
a) Main Area: Several sprinklers were loaded with dust.
b) Outpatient Office: One fire sprinkler deflector was measured to be 1/2 inch below its escutcheon.
c) Kitchen Simulation: Loose escutcheon exposing the annular space of the sprinkler pipe.
d) Dialysis: Loose escutcheon exposing the annular space of the sprinkler pipe.
e) Charting: One fire sprinkler deflector was measured to be 1/4 inch below its escutcheon.
f) Gym: One sprinkler was corroded.

11) Doctor's Dictation Room: Loose escutcheon exposing the annular space of the sprinkler pipe and blocking the deflector.

12) Staff Lounge: Loose escutcheon exposing the annular space of the sprinkler pipe.

13) Housekeeping: Sprinkler was loaded with dust.

14) Outside of 100 Hall: Sprinkler was missing its escutcheon.

15) Chief Nurse Officer Office: One fire sprinkler deflector was measured to be less than an inch below its escutcheon.

16) Resident Rooms:
a) 200: Loose escutcheon in the bathroom exposing the annular space of the sprinkler pipe.
b) 202: One fire sprinkler deflector was measured to be less than an inch below its escutcheon.
c) 209: One fire sprinkler deflector above bed B was measured to be less than an inch below its escutcheon.
d) 210: Missing escutcheon in the bathroom.
e) 217: Missing escutcheon above bed A; Loose escutcheon in the bathroom exposing the annular space of the sprinkler pipe.
f) 101: Missing escutcheon.
g) 108: Sprinkler corroded.
h) 109: Missing escutcheon in the bathroom.
i) 110: Loose escutcheon in the bathroom exposing the annular space of the sprinkler pipe.
j) 111: Sprinkler corroded.
k) 114: Missing escutcheon.
l) 117: Loose escutcheon in the bathroom exposing the annular space of the sprinkler pipe.

17) Interstitial space above dropped ceiling near Resident Room 101: Conduit was resting on the sprinkler piping.

18) Interstitial space above dropped ceiling near Resident Room 127: Conduit was resting on the sprinkler piping.

The Chief Financial Officer and Regional Director of Plant Operations acknowledged the deficiencies at the time of discovery.

Based on observation and interview, the facility failed to protect corridor openings due to doors that would not resist the passage of smoke. This deficient practice affected two of six smoke compartments, their residents, staff and guests.

Findings include:

On 05/10/17, during the tour of the facility the following corridor doors would not resist the passage of smoke as evident by their inability to latch.
a) Resident Room 205
b) Resident Room 104

The Regional Director of Plant Operations acknowledged the deficiencies at the time of discovery.

Based on observation and interview, the facility failed to ensure smoke barrier doors would properly close when released from their hold-open devices. This deficient practice affected two of six smoke compartments, their residents, staff and guests.

Findings include:

On 05/10/17, observation of the cross-corridor doors near resident room 101 revealed the leading edges on the lower portion of each door were not aligned. The alignment of the doors kept the astragals from properly sealing the doors and was one inch or greater.

The Regional Director of Plant Operations acknowledged the deficiency at the time of discovery.

Based on observation, record review and interview, the facility failed to 1) conduct fire drills as required and 2) ensure staff members were familiar with fire response procedures. This deficient practice affected six of six smoke compartments, their residents, staff and guests.

Findings include:

1) On 05/09/17, record review revealed the fire drills for three quarters were not held at unexpected times under varying conditions as fire drills were conducted at or near the same time each shift.

2) On 05/10/17 at 3:10 PM, a fire drill was conducted and simulated to be in the Sahara Dayroom. Employee #5 responded to the drill by pulling a manual fire pull box.

During the fire drill an overhead announcement was made informing all staff of the location for the simulated fire, but the announcement occurred over two minutes from when the manual fire alarm was pulled. The alarm panel noted "Mon Pull Sta", therefore Employee #6 did not know the exact location and asked for help with determining the fire location prior to making the announcement.

Observation of the 100 Hallway revealed doors left open to the Medical Dictation Room and an adjacent office.

Observation of the 200 Hallway revealed a patient bed was in the hall outside Resident Room 206 partially blocking the path of egress.

3) On 5/10/17 at 15:25, the fire pull box was tested and pulled in the Boiler Room and outside the Boiler Room; in both instances, the alarm panel noted "Mon Pull Sta" with a numerical ID. A smoke detector was tested outside the Boiler Room and the alarm panel noted "SD" with a numerical ID. The numerical ID was later found to correlate to a specific location listed on a fire alarm vendor report, however this information was not readily available when the fire alarm was activated.

Note: Locations displayed on fire alarm panel are utilized to inform staff and fire personnel of where a fire alarm device was activated. While the panels did provide a numerical ID, a list of the locations was not available by or near the panels. The absence of a location list created a delayed staff response that could have resulted in loss of life.

The Maintenance Mechanic and the Regional Director of Plant Operations acknowledged the deficiency at the time of discovery.

Based on observation and interview, the facility failed to 1) define proper receptacle containers for cigarette waste disposal in their smoking policy and 2) ensure smoking materials were appropriately disposed of in receptacle containers. These deficient practices affected four of six smoke compartments, their residents, staff and guests.

Findings include:

1) Cigarette Waste Disposal (Facility Policy)
On 05/09/17 and 05/10/17, a review of the facility's smoking policy revealed failure to describe the type and use of receptacle containers for disposal of cigarette butts and ashes.

2) Disposal of Smoking Materials with Trash
On 05/09/17 at 4:14 PM, observation of the smoking area outside the Main Dining Room revealed unlabeled, open metal pails with trash, cigarette butts and ashes being used for cigarette disposal.

On 05/10/17, the Regional Director of Plant Operations acknowledged the deficiencies.

Reference National Fire Protection Association (NFPA) 99, Health Care Facilities Code, 2012 Edition
6.4.2.2.3 Life Safety Branch.
6.4.2.2.3.1 The life safety branch shall be limited to circuits essential to life safety.
6.4.2.2.3.2 The life safety branch shall supply power for lighting, receptacles, and equipment as follows:
(1) Illumination of means of egress in accordance with NFPA 101, Life Safety Code
(2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code
(3)* Hospital communications systems, where used for issuing instruction during emergency Conditions
(4) Generator set location as follows:
(a) Task illumination
(b) Battery charger for emergency battery-powered lighting unit(s)
(c) Select receptacles at the generator set location and essential electrical system transfer switch locations
(5) Elevator cab lighting, control, communications, and signal systems
(6) Electrically powered doors used for building egress
(7) Fire alarms and auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm and Signaling Code
6.4.2.2.3.3 Alarm and alerting systems (other than fire alarm systems) shall be connected to the life safety branch or critical branch.
6.4.2.2.3.4 Loads dedicated to a specific generator, including the fuel transfer pump(s), ventilation fans, electrically operated louvers, controls, cooling system, and other generator accessories essential for generator operation, shall be connected to the life safety branch or the output terminals of the generator with overcurrent protective devices.
6.4.2.2.3.5 No functions other than those in 6.4.2.2.3.2, 6.4.2.2.3.3, and 6.4.2.2.3.4 shall be connected to the life safety branch, except as specifically permitted in 6.4.2 .2.3.
6.4.2.2.4* Critical Branch.
6.4.2.2.4.1 The critical branch shall be permitted to be subdivided into two or more branches.
6.4.2.2.4.2 The critical branch shall supply power for task illumination, fixed equipment, select receptacles, and select power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases, task illumination, select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected acute nursing areas, psychiatric bed areas (omit receptacles), and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) Nurses' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7)* Telephone equipment rooms and closets
(8) Task illumination, select receptacles, and select power circuits for the following areas:
(a) General care beds with at least one duplex receptacle per patient bedroom, and task illumination as required by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power circuits needed for effective facility operation, including single-phase fractional horsepower motors, which are permitted to be connected to the critical branch
6.4.2.2.5 Equipment Branch.
6.4.2.2.5.1 General. The equipment branch shall be connected to equipment described in 6.4.2.2.5.3 through 6.4.2.2.5.4.
6.4.2.2.5.2 Connection to Alternate Power Source.
(A) The equipment branch shall be installed and connected to the alternate power source, such that equipment described in 6.4.2.2.5.3 is automatically restored to operation at appropriate time-lag intervals following the energizing of the life safety and critical branches.
(B) The arrangement of the connection to the alternate power source shall also provide for the subsequent connection of equipment described in 6.4.2.2.5.4.
6.4.2.2.5.3* Equipment for Delayed-Automatic Connection.
(A) The following equipment shall be permitted to be arranged for delayed-automatic connection to the alternate power source:
(1) Central suction systems serving medical and surgical functions, including controls, with such suction systems permitted to be placed on the critical branch
(2) Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms
(3) Compressed air systems serving medical and surgical functions, including controls, with such air systems permitted to be placed on the critical branch
(4) Smoke control and stair pressurization systems
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood
(6) Supply, return, and exhaust ventilating systems for the following:
(a) Airborne infectious/isolation rooms
(b) Protective environment rooms
(c) Exhaust fans for laboratory fume hoods
(d) Nuclear medicine areas where radioactive material is used
(e) Ethylene oxide evacuation
(f) Anesthetic evacuation
(B) Where delayed-automatic connection is not appropriate, the ventilation systems specified
in 6.4.2.2.5.3(A)(6) shall be permitted to be placed on the critical branch.
6.4.2.2.5.4* Equipment for Delayed-Automatic or Manual Connection. The following equipment shall be permitted to be arranged for either delayed-automatic or manual connection to the alternate power source (also see A.6.4.2.2.5.3):
(1) Heating equipment used to provide heating for operating, delivery, labor, recovery, intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment spaces, and general patient rooms; and pressure maintenance (jockey or make-up) pump(s) for water-based fire protection systems
(2)* Heating of general patient rooms during disruption of the normal source shall not be required under any of the following conditions:
(a) Outside design temperature is higher than 6.7°C (+20°F)
(b) Outside design temperature is lower than 6.7°C (+20°F), where a selected room(s) is provided for the needs of all confined patients [then only such room(s) need be heated].
(3) Elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power
(4) Supply, return, and exhaust ventilating systems for surgical and obstetrical delivery suites, intensive care, coronary care, nurseries, and emergency treatment spaces
(5) Hyperbaric facilities
(6) Hypobaric facilities
(7) Autoclaving equipment, which is permitted to be arranged for either automatic or manual connection to the alternate source
(8) Controls for equipment listed in 6.4.2.2.4
(9)* Other selected equipment


Based on observation and interview, the facility failed to 1) ensure authorized functions were connected to the appropriate branches of the Essential Electrical System (EES) and 2) electrical connections in junction boxes were covered as required by NFPA 70. These deficient practices affected six of six smoke compartments, their residents, staff and guests.

Findings include:

1) On 05/09/17, observation of the panel schedules for the EES revealed the following:

a) Panel RP-EQ-A Sect. 1 (equipment branch), had the Fire Alarm Control Panel (FACP) breaker assigned to the panel box. This function is to be assigned to the Life Safety Branch.

b) Hospital communication systems could not be located on the Life Safety Branch, Critical Branch or Equipment Branch panel schedules.

NOTE: This facility has a Type 1-Essential Electrical System (EES). The panel schedules reviewed do not meet the requirements for a Type 1 EES as defined in NFPA 99, 2012 Edition. The facility must evaluate all connections to the EES and ensure they are assigned to the appropriate branches.

The Regional Director of Plant Operations acknowledged the deficiency at the time of discovery.

2) On 05/10/17, observation of the interstitial space above the dropped ceilings revealed electrical junction boxes were not covered in three of seven areas checked. The following areas above the dropped ceiling had open electrical junction boxes:

a) hallway by 100 nurse station - one junction box was not covered.
b) hallway by resident room 101 - one junction box was not covered.
c) hallway by resident room 127 - one junction box was not covered.

The Regional Director of Plant Operations acknowledged the deficiencies at the time of discovery.

National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems (2010 Edition)
8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.


Based on interview and a review of the records, the facility failed to demonstrate the emergency power supply system (EPSS) was inspected weekly. This deficient practices affected six of six smoke compartments, their residents, staff and guests.

Findings include:

On 05/09/17, record review revealed the EPSS was exercised under load monthly. The records did not provide evidence that the EPSS was inspected weekly.

On 05/09/17 the Maintenance Mechanic explained only the monthly load tests were conducted and that weekly inspections if and when accomplished were not documented.

The Regional Director of Plant Operations and Chief Executive Officer, acknowledged the deficient practice during the exit interview.

Ref: NFPA 70
National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition

Article 400 - Flexible Cords and Cables
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 the Code
(7) Where subject to physical damage


Based on observation and interview, the facility failed to maintain electrical wiring and equipment in compliance with National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition. These deficient practices affected four of six smoke compartments, their residents, staff and guests.

Findings include:

1) On 05/10/17 at 10:57 AM, observation of the Pharmacy revealed a relocatable power tap (RPT) used to power a mini refrigerator.

2) On 05/10/17 at 11:25 AM, observation of the Nurse Manager Office revealed a RPT used to power a mini refrigerator and an uninterrupted power supply (UPS).

3) On 05/09/17 at 3:00 PM, observation of the Business Office revealed the following:
a) An extension cord was used to power a coffee pot and water cooler.
b) An extension cord was plugged into an outlet, under a cubical desk, but not currently in use.

4) On 05/09/17 at 3:05 PM, observation of the Admissions Office revealed a RPT with a mini refrigerator and a brown extension cord plugged in.

5) On 05/09/17 at 3:25 PM, observation of Central Supplies revealed a RPT plugged into another RPT.

6) On 05/09/17 at 3:57 PM, observation of the Maintenance Office revealed a RPT plugged into another RPT.

The Chief Financial Officer, Maintenance Mechanic and or the Western Regional Director of Plant Operations acknowledged the deficiencies at the time of discovery.

NOTE: The facility must ensure that the capacity for circuit breakers powering duplex receptacles is not exceeded. The use of RPTs to power refrigerators, coffee makers, and microwaves (to name a few high amp devices) raises concern for overloading circuit breakers. Mapping of the circuits within the building is strongly recommended for monitoring and re-assigning electrical appliances as needed.