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Observations revealed that the fire barrier separating the clinic from the hospital did not meet the requirements for two hour fire separation and is not in accordance with NFPA 101 "The Life Safety Code" 2000 edition (LSC) section 19.1.1.4.3,. These deficient practices could allow the products of combustion to travel from one building to another, which could negatively impact all the patients, staff and visitors of the facility.

Findings include:

On facility tour between 9:30 AM to 3:30 PM on 09/05/2012, observation revealed, that the 2 hour fire barrier/separation between the clinic (Business Occupancy) and the Hospital (Institutional-2 Occupancy) had a penetration around wirers that were located above the door.


These deficient practices were confirmed by the Maintenance Director (TJ).

Based on observations, the facility had penetrations in the corridors that are not in compliance with NFPA Life Safety Code 101 (00) Sections 19.3.6.2 and 8.2.4.4.1 in resisting the passage of smoke. This deficient practice could affect the exiting of patients, staff and visitors. In the event of a fire in this space, smoke and fire could spread into the corridor making it untenable.

Findings include:

On facility tour between 9:30 AM to 3:30 PM on 09/05/2012, it was observed that there were penetrations around the fire sprinkler piping and an electrical conduit that located above the smoke barrier doors outside patient room 212.


These deficient practices were confirmed by the Maintenance Director (TJ).

Based on observations, the facility has failed to provide proper protection for 1 of several hazardous areas located throughout the facility in accordance with NFPA Life Safety Code 101 (2000 edition) section 19.3.2.1. The following deficient practices could affect patients, staff and visitors as smoke and fire in this rooms could enter the corridor making it untenable.

Findings include:

On facility tour between 9:30 AM to 3:30 PM on 09/05/2012, observation revealed that the equipement storage room located in the corridor leading to the boiler room was not equipped with a self closing fire rated door.


These deficient practices were confirmed by the Maintenance Director (TJ).

Based on observation and staff interview, the facility failed to maintain a fire resistance rating of at least two hour in the exit component accordance with the following requirements of 2000 NFPA 101, Section 19.3.1.2, 8.2.5.2 and 7.1.3.2.1 (e). These deficient practices could allow the products of combustion to travel from the affected building and into the exiting component making it untenable, which could negatively impact all the patients, staff and visitors of the facility.


Findings include:

On facility tour between 9:30 AM to 3:30 PM on 09/05/2012, observation revealed, that the exit stairwell leading from the main level to the basement had a 1/4" wide by 8" long crack in block wall that went all the way through the blocks in the upper left hand corner of the basement level door frame.


These deficient practices were confirmed by the Maintenance Director (TJ).

Based on observations, it was determined that the facility failed to provide exit discharges that were readily accessible (free and unobstructed) at all times in accordance with NFPA 101-2000 edition, Sections 19.2.7, 7.1, 7.1.10 and 7.5.4. This was due to the lack of a hard path to a public way at 1 of 6 exits. This deficient practice could affect all patients, staff and visitors if emergency evacuation via this discharge was necessary.

Findings include:

On facility tour between 9:30 AM to 3:30 PM on 09/05/2012, it was observed that the exit discharge from the southeast patient wing was not provided with a hard surfaced path the leads to a public way. The current exit discharge located at the southeast patient exit has a concrete pad that has a 6 inch drop from the concrete to the ground and is situated on an uneven downward slope that reached an angle greater than 60 degrees that sloped away from the building.


These deficient practices were confirmed by the Maintenance Director (TJ).

Based on review of reports, records and interview, it was determined that the facility failed to conduct the required number of fire drill in the last 12-month period. This deficient practice could affect how staff react in the event of a fire. Improper reaction by staff would affect the safety of all patients, visitors and staff.

Findings include:

On facility tour between 9:30 AM to 3:30 PM on 09/05/2012, during a documentation review of the available fire drill reports for the last 12 months and interview with the Maintenance Director (TJ), it was revealed that the facility failed to ensuring their compliance with the one per shift per quarter fire drill requirements for Institutional/Healthcare occupancies by failing to conduct one the four required fire drill for the overnight shift during in the third quarter and failed to vary the times of the overnight fire drills by conducting 3 fire drills in the 6 AM hour during the last 12 months.


These deficient practices were confirmed by the Maintenance Director (TJ).

Based on observation and staff interview, the facility failed to install and maintain the fire alarm system in accordance with the requirements of 2000 NFPA 101, Sections 19.3.4.1 and 9.6, as well as 1999 NFPA 72, Sections 2-3.4.5.1.2, 2-3.5.1. These deficient practices could adversely affect the functioning of the fire alarm system that could delay the timely notification and emergency actions for the facility thus negatively affecting all patients, staff, and visitors of the facility.


Findings include:


On facility tour between 9:30 AM to 3:30 PM on 09/05/2012, observation revealed, that the following deficient conditions were identified:

1. The facility failed to conduct 7 of 12 monthly tests of the fire alarm DACTsystem, and

2. In the Doctor's On-Call sleeping room there were no audible fire alarm sounding devices in conjunction with the fire alarm smoke detection head to notify sleeping staff in the room of an alarm activation.


These deficient practices were confirmed by the Maintenance Director (TJ).

Based on interview and review of available documentation, the facility has not been conducting sensitivity testing of the smoke detectors on the fire alarm system in accordance with NFPA 72 (99), Sec. 7-3.2.1. This deficient practice could affect all patients, visitors, and staff.

Findings include:

On facility tour between 9:30 AM to 3:30 PM on 09/05/2012, a review of the facility's available fire alarm test documentation revealed that the facility failed to provide any documentation that the required sensitivity test of each smoke detector had been conducted.


These deficient practices were confirmed by the Maintenance Director (TJ).

Based on observations, the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems (99). The failure to maintain the sprinkler system in compliance with NFPA 13 (99) could allow damage to the sprinkler piping that would cause failures in the system and affect all residents, visitors and staff of the facility.

Findings include:

On facility tour between 9:30 AM to 3:30 PM on 09/05/2012, observation revealed, that the following deficient conditions were identified:

1. The sprinkler piping located in the maintnenance office had non-system components and wires attached to the pipes, and

2. That the spare fire sprinkler head box was not equipped with at least 2 of every type and style of sprinkler heads that are being used in the facility. The observed missing spare sprinkler head was the same type and style as the ones located in the sprinkler riser room where the spare sprinkler head box was located.


These deficient practices were confirmed by the Maintenance Director (TJ).

Based on observations the facility failed to keep the means of egress continuous and free of all obstructions or impediments to full instant use in the case of fire or other emergency, in accordance with NFPA Life Safety Code 101 (2000 edition) Chapter 7, Section 7.1.10. These obstructions could interfere with the convenient and effective removal all patients, staff and visitors in an emergency situation, and impede fire fighting operations during a fire emergency.


Findings include:

On facility tour between 9:30 AM to 3:30 PM on 09/05/2012, it was observed that there were pallets, boxes and other combustibles being stored in the corridors by the boiler room. This deficient practice is reducing the corridor clear width and obstructing the full and instant access and use of the corridor in the event of an emergency.


These deficient practices were confirmed by the Maintenance Director (TJ).