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Based on observation and interview, the facility failed to ensure there was no impediment to closing corridor doors. This was evidenced by self closing doors for Central Supply and the surgery staff lounge that were obstructed from closing by metal door wedges. This could result in a delay to contain fire or smoke during a fire emergency. This affected one of five smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.6.3 Corridor Doors.
19.3.6.3.2* Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: Existing roller latches demonstrated to keep the door closed against a force of 5 lbf (22 N) shall be permitted to be kept in service.

7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.4

Findings:

During the facility tour and interview with Facilities Staff 1 on 7/27/16, the self closing doors were observed.

1. At 8:39 a.m., the self closing door to the surgery staff lounge was obstructed from closing by a metal door wedge that held the door in the fully open position.

2. At 8:45 a.m., the self closing door to Central Supply was obstructed from closing by a metal door wedge that held the door in the fully open position. At 8:46 p.m., Facilities Staff 1 confirmed that the doors were obstructed from closing.

Based on observation and interview, the facility failed to maintain doors in smoke barrier walls. This was evidenced by an automatic closing smoke barrier door that failed to close completely. This could result in the spread of smoke or fire from one smoke compartment to another during a fire emergency. This affected two of five smoke compartments.

NFPA 101, Life Safety Code 2000 edition
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
19.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area
enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The
automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be
arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors
installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National
Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that
stair.

Findings:

During the facility tour and interview with Maintenance Staff 1 on 7/26/16, the smoke barrier doors were observed.

1. At 4:26 p.m., the automatic closing door located in the smoke barrier wall for Room 110 failed to close the last four inches when the door was released by activation of the fire alarm system. At 4:27 p.m., Maintenance Staff 1 explained that the door was deformed and obstructed from closing due to delaminating of the sheathing on one side of the door.

Based on observation and interview, the facility failed to maintain readily available exit access to the public way. This was evidenced by panic hardware that failed to release the latch and open a door in a direct exit from the dining room. This could result in a delayed evacuation, in the event of a fire, and affected one of five smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
7.1.9 Impediments to Egress. Any device or alarm installed to restrict the improper use of a means of egress shall be designed and installed so that it cannot, even in case of failure, impede or prevent emergency use of such means of egress unless otherwise provided in 7.2.1.6 and Chapters 18, 19, 22, and 23.
7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings:

During the facility tour and interview with Facilities Staff 1 on 7/27/16, the access to exits were observed.

1. At 8:22 a.m., the east leaf on the west set of double doors leading from the dining area to the exterior patio was obstructed from opening. The panic hardware failed to release the latch and open the door when tested three times. At 8:23 a.m., Facilities Staff 1 acknowledged that the latch had failed in the locked position.

Based on observation and interview, the facility failed to ensure all battery back-up emergency lighting units were fully operational. This was evidenced by a failure of the battery back-up ballast in one of eight fluorescent lights in Operating Room (OR) 2 and one wall pack emergency light in surgery recovery area that failed to illuminate when tested. This affected one of five smoke compartments and could result in limited visibility in the event of a power failure.

NFPA 101 Life Safety Code, 2000 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During the facility tour and interview with Facility Staff 1 on 7/27/16, the emergency battery back-up lighting was observed and the inspection records were requested.

1. At 8:34 a.m., the battery power indicator light failed to illuminate on one of eight battery back-up ballast fluorescent light assemblies in OR #2. At 8:35 a.m., Facilities Staff 1 stated that there was no scheduled replacement of the battery back-up ballast lights and that it had been approximately four years since contractors had done this type of lighting service work. At 8:36 a.m., Facilities Staff 1 confirmed there was no equipment manual available for the fluorescent lights with the battery ballasts.

2. At 8:50 a.m., the battery back-up wall pack in the surgery recovery area failed to illuminate when the test button was operated. At 8:51 p.m., Facilities Staff 1 acknowledged that the equipment descriptions on the preventative maintenance testing was not specific enough for all locations.

Based on observation and interview, the facility failed to maintain a fully functional fire alarm system. This was evidenced by the facility's failure to restore the fire alarm system to normal operating condition and staff maintaining the remote annunciator in a silenced mode due to the ongoing trouble alarms. This affected five of five smoke compartments and could result in a delayed notification of a fire emergency to staff and emergency response entities.

NFPA 101 Life Safety Code (2000 Edition)
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.4.6.1 Visible and audible trouble signals and visible indication of their restoration to normal shall be indicated at the following locations:
(1) Control unit (central equipment) for protected premises fire alarm systems
(2) Building fire command center for emergency voice/alarm communications service
(3) Central station or remote station location for systems installed in compliance with Chapter 5

7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

7-1.1.2 System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner's designated representative shall be informed of the impairment in writing within 24 hours.

Findings:

During the facility tour and interview with the Receptionist Staff 1 and Facility Staff 1 on 7/27/16, the fire alarm control panel and remote annunciator at the receptionist desk was observed.

1. At 11:52 a.m., there was a trouble light indicated on the fire alarm control panel. At 11:53 a.m., Facilities Staff 1 explained that their vendors were on-site to troubleshoot and repair the problem in the notification circuit. From 11:53 a.m. to 12:58 p.m., receptionist staff were observed silencing the trouble and tamper alarms at the remote annunciator. At 12:08 p.m., Receptionist Staff 1 explained that they normally silence the trouble alarms and could not distinguish between a tamper alarm or a trouble alarm.

Based on observation and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by two sprinkler heads that were obstructed, by one sprinkler head escutcheon that was missing, and by one escutcheon that was displaced. This was also evidenced by 4 sprinkler heads under the main entrance canopy and two under a second entrance canopy that were loaded with spider webs and debris. This affected three of five smoke compartments and could result in a delay in activation of the fire sprinkler system or a delay in notification during a fire emergency.

NFPA 101, Life Safety Code, 2000 Edition.
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
9.7.1 Automatic Sprinklers.
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Exception No. 1: NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted for use as specifically referenced in Chapters 24 through 33 of this Code.
Exception No. 2: NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, shall be permitted for use as provided in Chapters 24, 26, 32, and 33 of this Code.
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, Installation of Sprinkler Systems, 1999 edition
5-5.5.3 Obstructions that Prevent Sprinkler Discharge from Reaching the Hazard. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm)below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 5-5.5.3.
5-5.6 Clearance to Storage. 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, 1998 Edition.
2-2.1.1* Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1:* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.
2-2.2 Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Findings:

During the facility tour and interview with Kitchen Staff 1 on 7/27/16, the automatic sprinkler system was observed.

1. At 7:50 a.m., there were 4 sprinkler heads that were located in the main entrance canopy that were loaded with spider webs and debris.

2. At 8:30 a.m., the sprinkler head in the dry goods storage area was obstructed by boxed goods stored less than 8 inches below the sprinkler head. The sprinkler did not have 18 inches of clearance.

3. At 8:31 a.m., the sprinkler head in the walk in freezer was obstructed by boxed goods stored less than 10 inches below the sprinkler head. At 8:32 a.m., Kitchen Staff 1 explained that they had just put away a shipment of cartooned goods and that they aren't normally stacked as high. The sprinkler did not have 18 inches of clearance.

4. At 9:25 a.m., in Medical Records there was 1/2 inch space between the ceiling and the sprinkler head escutcheon located over the rolling fire rack area.

5. At 9:30 p.m., in the Admitting Office there was a missing escutcheon on the sprinkler head.

6. At 10:05 p.m., there were 2 sprinkler heads that were located under the canopy near Acute Nursing that were loaded with spider webs and debris.

Based on observation, interview, and record review, the facility failed to maintain their fire/smoke dampers. This was evidenced by incomplete records of inspection and testing all fusible link type fire dampers not less than every four years. This affected five of five smoke compartments and could result in the spread of smoke or fire to other locations of the facility due to a malfunctioning fire/smoke damper.

NFPA 101, Life Safety Code 2000 edition
19.5.2.1 Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications.
Exception: As modified in 19.5.2.2.

9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with
NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems 1999 edition
3-4.7 At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During record review and interview with Facilities Staff 1 on 7/26/16, the test and maintenance records for all fire/smoke dampers were requested.

1. At 3:55 p.m., there were incomplete records that indicated the facility had tested, cleaned, lubricated, or inspected their fire/smoke dampers during the past four years. The last record, dated 7/3/13, indicated that 24 fire/smoke type dampers were tested. There were no records indicating that fusible-link type fire dampers were inspected and tested.

During the facility tour and interview with Facilities Staff 1 on 7/27/16 p.m., fusible link type fire/smoke dampers were observed. From 8:05 a.m. to 3:20 p.m., the supply and return air registers throughout the facility were observed. At 3:21 p.m., Facilities Staff 1 acknowledged that there were hundreds of the fusible-link type dampers in the facility that were not included in the vendor's testing report dated 7/3/13.

Based on observation and interview, the facility failed to ensure that portable space heaters were operated according to the manufacturer's specifications. This was evidenced by a high temperature space heater that was plugged into an electrical outlet in an area that lacked adequate clearance space from combustibles. This could result in the spread of fire and smoke affecting one of five smoke compartments.

NFPA 101 Life Safety Code, 2000 Edition
19.7.8 Portable Space-Heating Devices. Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212·
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70 National Electrical Code, 1999 Edition
110-3 Examination, Identification, Installation and use of Equipment
(b) Installation and use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

Findings:

During a facility tour and interview with Facilities Staff 1 on 7/27/16, a portable space heater was observed.

1. At 9:08 a.m., there was a portable space heater plugged into a wall outlet and placed less than one foot from boxed combustible storage items under the desk in the Dietary Supervisor's office. The space heater label on the side of the device included the following warning:

"CAUTION - High temperature, keep electrical cords, drapery, and other furnishings at least 3 feet(0.9m) from the front of the heater and away from the side and rear."

At 9:11 a.m., the heater was moved around in the office to test clearance potential. Facilities Staff 1 confirmed that there was not enough room in the small office where the heater could be placed to achieve three feet of clearance from furnishings or combustible materials.