Hendrick Hospice Care Inc.

“Reference: NFPA 101, Life Safety Code, 2012 Edition .18.1.3 Multiple Occupancies. 18.1.3.1 Multiple occupancies shall be in accordance with 6.1.14. 18.1.3.2 Sections of health care facilities shall be permitted to be classified as other occupancies in accordance with the separated occupancies provisions of 6.1.14.4 and either 18.1.3.3 or 18.1.3.4. 18.1.3.4 Contiguous Non-Health Care Occupancies. 18.1.3.4.1 Ambulatory care facilities, medical clinics, and similar facilities that are contiguous to health care occupancies, but are primarily intended to provide outpatient services, shall be permitted to be classified as business occupancies or ambulatory health care facilities, provided that the facilities are separated from the health care occupancy by not less than 2-hour fire resistance–rated construction, and the facility is not intended to provide services simultaneously for four or more inpatients who are litterborne. 6.1.14.4.2 Occupancy separations shall be classified as 3-hour fire resistance-rated, 2-hour fire resistance-rated, or 1-hour fire resistance-rated and shall meet the requirements of Chapter 8. 6.1.14.4.3 The minimum fire resistance rating specified in Table 6.1.14.4.1(a) and Table 6.1.14.4.1(b) shall be permitted to be reduced by 1 hour, but in no case shall it be reduced to less than 1 hour, where the building is protected throughout by an approved automatic sprinkler system in accordance with 9.7.1.1(1) and supervised in accordance with 9.7.2, unless prohibited by the double-dagger footnote entries in the tables. 6.1.14.4.4 Occupancy separations shall be vertical, horizontal, or both or, when necessary, of such other form as required to provide complete separation between occupancy divisions in the building. NFPA 101, Tables 6.1.14.4.1(a) and 6.1.14.1(b) Required Separation of Occupancies (hours), Parts 1 and 2 Health Care and all occupancies (unless another Health Care occupancy) are to have a minimum 2-hour rated fire barrier. Additionally, the 1-hour reduction due to the presence of sprinklers is not permitted. NFPA 101, 8.3 Fire Barriers8.3.1 General 8.3.1.2 Fire barriers shall comply with one of the following:(1) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces.(2) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, and from the floor to the bottom of the interstitial space, provided that the construction assembly forming the bottom of the interstitial space has a fire resistance rating not less than that of the fire barrier. Based on observation and interview, the facility failed to ensure 1 of 1 fire barrier wall, separating the inpatient care from the Bereavement Center, was constructed by a system or material capable of restricting the transfer of smoke and fire to ensure a 2-hour fire resistance rating, according to NFPA 101, 18.1.3, 18.1.3.1, 18.1.3.2, 18.1.3.4, 6.1.14.4.1, 6.1.14.4.2, 6.1.14.4.3, 6.1.14.4.4, and 8.3.1.2. The fire barrier wall had unsealed openings. This failure to ensure the fire barrier wall was constructed to restrict the transfer of smoke and fire could result in smoke or fire extending from the Bereavement Center to the inpatient care. This could allow the residents of the inpatient care to incur fire related injuries or smoke inhalation. Findings include: Observation on 11/19/2025 at 1:17 p.m., accompanied by the Facility Manager, revealed the Bereavement Center side of the fire barrier wall had an approximately 4-inch missing section of gypsum underneath an approximately 4-inch pipe penetrating the fire barrier wall. Further observation revealed the circumference of the pipe was not sealed. On the opposite side of the fire barrier wall (inpatient side), the same 4-inch pipe penetrating the fire barrier wall was not sealed around the pipe. Observation on 11/19/2025 at 1:18 p.m., accompanied by the Facility Manager, revealed the inpatient side of the fire barrier wall had four unsealed screw sized openings to the right of fire barrier access door. In an interview with the Facilities Director on 11/20/2025 at approximately 10:00 a.m., he stated he was not aware of the holes in the 2-hour fire wall prior to the inspection. He went on to state that a vendor has been contacted to repair the holes because he wants to ensure the holes are sealed properly by professional contractor that meets the 2-hour barrier requirements. He further stated that he was aware of the requirements that there cannot be any holes in the firewall. He further stated that with the holes in the walls it could allow the transfer of smoke and fire to adjacent areas of the facility causing smoke and fire related burns to the facility.”

“References: NFPA 101, Life Safety Code, 2012 Edition, Chapter 18, New Health Care Occupancies. 18.3.2 Protection from Hazards. 18.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system inaccordance with 8.7.1. 18.3.2.1.1 An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 18.3.5.9. 18.3.2.1.2 Where the sprinkler option of 18.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4. 18.3.2.1.3 The doors shall be self-closing or automatic-closing. 3.3 General Definitions. 3.3.30 Automatic. Capable of performing a function without the necessity of human intervention. 3.3.238 Self-Closing. Equipped with an approved device that ensures closing after opening. 8.4 Smoke Partitions. 8.4.1 General. Where required elsewhere in this Code, smoke partitions shall be provided to limit the transfer of smoke. 8.4.2 Continuity. Smoke partitions shall comply with the following: (1) They shall extend from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitialstructural and mechanical spaces. (2) They shall be permitted to extend from the floor to the underside of a monolithic or suspended ceiling system where all of the following conditions are met: (a) The ceiling system forms a continuous membrane.(b) A smoke-tight joint is provided between the top of the smoke partition and the bottom of the suspended ceiling. Based on observation and interview, the facility failed to maintain separation of 2 of approximately 8 hazardous areas from other spaces in the facility: a) Room 172 and Room 150 according to NFPA 101, 8.4.2 (1)(2)(b) as referred to by 18.3.2.1.2.b) Room 156 according to NFPA 101 18.3.2.1. Concealed spaces above the drop ceiling had unsealed openings and penetrations and a hazardous room was over 50 square feet, used as storage, and did not have a self-closing device on the door. These failures could result in the rapid spread of fire and smoke into the egress corridor of the Service Hall in the event of a fire emergency which could cause fire and smoke inhalation related injuries and affect the health and safety of residents residing on the East Hall. Findings included: a) Observation on 11/19/2025 at 2:44 p.m., accompanied by Facility Compliance, revealed the Supply Storage, Room 172, had an approximately 1 ½ inch unsealed opening in the smoke partition above the drop ceiling. In an interview on 11/20/2025 at 10:32 a.m. with Facility Compliance, when asked if he knew the requirement for maintaining the smoke partition with no unsealed openings, he related he was aware. When asked if he knew what caused the unsealed opening or how long the openings had been in the smoke partition, he stated he did not know. When asked who was responsible for maintaining the smoke partition, he said the Compliance Department was responsible. The Facility Compliance acknowledged this failure could result in the rapid spread of fire and smoke into the egress corridor of the Service Hall in the event of a fire emergency which could cause fire and smoke inhalation related injuries and affect the health and safety of residents residing on the East Hall. a) Observation on 11/19/2025 at 2:59 p.m., accompanied by Facility Compliance, revealed the Storage Room, Room 150, had an approximately 4-inch circular unsealed opening around an approximately 3-inch pipe penetrating the wall in the smoke partition above the drop ceiling. In an interview on 11/20/2025 at 10:34 a.m. with Facility Compliance, when asked if he knew the requirement for maintaining the smoke partition with no unsealed openings, he related he was aware. When asked if he knew what caused the unsealed opening or how long the opening had been in the smoke partition, he stated he did not know. When asked who was responsible for maintaining the smoke partition, he said the Compliance Department was responsible. The Facility Compliance acknowledged this failure could result in the rapid spread of fire and smoke into the egress corridor of the Service Hall in the event of a fire emergency which could cause fire and smoke inhalation related injuries and affect the health and safety of residents residing on the East Hall. b) Observation on 11/19/2025 at 2:54 p.m., accompanied by Facility Compliance, revealed Room 156, used as Pharmacy Storage, was over 50 square feet and contained numerous cardboard boxes and numerous plastic storage bins. Further observation revealed the door to Room 156 was not equipped with a self-closing device. In an interview on 11/20/2025 at 10:25 a.m. with Facility Compliance, when asked if he knew the requirement for maintaining the door to the storage room with a self-closing device, he related he was aware of the requirement. When asked if he was aware the door to Room 156 was not equipped with a self-closing device, he stated he did not have a key to that storage room therefore he was not aware the door was not equipped with a self-closing device. When asked who was responsible for maintaining the door with a self-closing device, he said the Compliance Department was responsible. The Facility Compliance acknowledged this failure could result in the rapid spread of fire and smoke into the egress corridor of the Service Hall in the event of a fire emergency which could cause fire and smoke inhalation related injuries and affect the health and safety of residents residing on the East Hall.”

“References:2012 NFPA 101 Life Safety CodeChapter 18 New Health Care Occupancies18.3.5 Extinguishment Requirements.18.3.5.1 Buildings containing health care occupancies shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 18.3.5.5.9.7 Automatic Sprinklers and Other Extinguishing Equipment.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 one of the following:(1) NFPA 13, Standard for the Installation of Sprinkler Systems(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height2010 NFPA 13, Standard for the Installation of Sprinkler SystemChapter 6 System Components and Hardware6.2 Sprinklers.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.Chapter 8 Installation Requirements8.2.4 Multiple buildings attached by canopies, covered breezeways, common roofs, or a common wall(s) shall be permitted to be supplied by a single fire sprinkler riser. The maximum system size shall comply with 8.2.1.8.2.5 Detached Buildings.8.2.5.1 Unless the requirements of 8.2.5.2 apply, detached buildings, regardless of separation distance, that do not meet the criteria of 8.2.4 shall be provided with separate fire sprinkler systems.8.2.5.2 When acceptable to the authority having jurisdiction, detached structures shall be permitted to be supplied by the fire sprinkler system of an adjacent building.(A) Based on observation and interview, the facility failed to ensure system components and hardware were installed on two sprinkler heads in 2 of 2 hallways (Hallway West room 106, Hallway East outside awning), according to NFPA 13, 6.2.7 and 6.2.7.1 as referred to by NFPA 101, 19.3.5.12 sprinkler heads had missing hardware (escutcheon and concealed head cover). These deficient practices could create deficiencies and/or impairments affecting residents dependent on the sprinkler system for fire extinguishment or containment in the event of a fire, exposing residents to smoke inhalation and fire-related burns.Findings included:Observation on 11-19-2025 revealed a complete NFPA 13 sprinkler system. Observation at 11:00 am revealed the escutcheon on the sprinkler head located in the east hall outside awning (1 of 1 escutcheon), was missing. Observation in the west hall room 106 at 2:45 pm revealed a sprinkler missing the concealed head cover (1 of 5 concealed head cover). In an interview with the Director on 11-20-2025 at 10:00 am, He stated he was not aware the escutcheon and concealed head cover were missing prior to survey, he went on to state he relies on his staff and sprinkler contractor to make sure the system is inspected to meet all regulations. He further stated with the missing and hanging escutcheons could allow the passage of smoke and fire to different smoke compartments and could cause smoke inhalation and fire related burns to the residents in the facility.(B)Based on observations and interviews, the facility did not ensure that one of one combustible wood structures attached to the existing building was protected with a sprinkler system in accordance with NFPA 13, 8.2.4 and 8.2.5, as referenced in NFPA 101, sections 18.3.5.1 and 9.7.The facility failed to install a sprinkler system to protect an attached wood-framed building that was not equipped with one.Although no actual harm has occurred, this deficiency could affect future residents, leading to smoke inhalation and fire-related injuries if a fire occurs in this building because of its combustible construction. Eight patients were present at the facility during the initial inspection.Findings include:During observations on 11/19/2025, it was noted that a three-sided wooden storage shed was attached to the exterior of the north resident wing of the building. No sprinkler coverage was installed for the storage shed, as required by NFPA 101, 9.7.During interviews on 11/19/2025 at 10:30 a.m. and 4:20 p.m., the facility management director stated he was unaware that the shed was not protected with a sprinkler system. The survey team measured the shed to be approximately 87 square feet (7’-8” x 11’-4”), attached to the exterior brick face of the building. It is used to protect the above-ground plumbing and pumps of the water feature in the exterior yard between the two patient care wings from freezing, as happened in February 2021.During an interview with the Director, he stated that the sprinkler system company would be contacted to extend the existing sprinkler system to protect the woodshed from fire. He mentioned that he understood this could pose a fire hazard if left unprotected, potentially resulting in burns and smoke inhalation among the facility’s residents.”

“References: NFPA 101 2012 Edition.Chapter 9 Chapter 9 Building Service and Fire Protection EquipmentChapter 9.7 Automatic Sprinkler and Other Extinguishing Equipment 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.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 Based on observation and interview, the facility failed to ensure sprinkler heads on 1 of 2 halls outside the awning (Hall East) were free of corrosion, foreign materials, paint, and physical damage according to NFPA 25, 5.2.1.1.1, 5.2.1.1.2, 5.2.1.1.4. The facility failed to maintain the sprinkler heads free of foreign materials. (Mud) This deficient practice could cause the fire sprinkler system to malfunction, affecting the health and safety of individuals due to exposure to fire-related burns and smoke inhalation, in a fire-related emergency. Findings: During an observation on 11-19-2025 at 11:00 am, 1 of 2 halls (Hall East) had foreign materials on them. (Mud) During an interview with the Director on 11-20-2025 at 10:00 am, He stated the sprinkler system company would be contacted to get the sprinkler head cleaned or replaced. He was not aware of the issue prior to the survey visit and said it would be resolved. He also stated that he is aware of the requirement that the sprinkler heads have to be kept clean. He went on to state that with the foreign materials and corrosion it could cause the sprinkler system to not work properly causing fire related burns and smoke inhalation to the residents in the facility.”

“References: NFPA 101, Life Safety Code, 2012 editionChapter 18 New Health Care Occupancies18.3.7 Subdivision of Building Spaces18.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating. NFPA 101, Life Safety Code, 2012 edition8.5 Smoke Barriers. 8.5.1 General. Where required by Chapters 11 through 43, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke. Based on observations and interviews, the facility failed to ensure smoke barriers were constructed to a 1/2-hour fire resistance rating for 1 of 2 smoke barriers (East Hall) inspected for smoke resistance, according to NFPA 101, 8.5.1 as referred to by NFPA 101, 18.3.7.3. The smoke barrier was not constructed to provide a minimum 1/2-hour fire resistance rating. This deficient practice could affect residents of the facility, especially those residing on the East Hall, in the event of a fire, exposing residents to smoke inhalation or other fire related injuries. Findings included: Observation on 11/19/2025 at 2:12 p.m., accompanied by the Facility Manager, revealed the smoke barrier wall, located in the attic space, on East Hall B had the following unsealed openings: 1) An approximately 2-inch by 2-inch squared unsealed opening with two ½ inch conduit penetrating the opening2) An approximately 1-inch circular unsealed opening3) An approximately 1-foot by 2-inch separation, unsealed opening, between two sheets of gypsum In an interview with the Director on 11-20-2025 at 10:00 am, He stated he was not aware of the holes in smoke wall prior to the inspection. He went on to state a work order has been created and the repairs will be done by the facility. He also stated with the holes in the smoke wall it could allow the smoke to adjacent areas causing smoke inhalation to the residents in the facility. He further stated that he was aware of the requirements that there cannot be any holes in the smoke wall.”

“References:2012 NFPA 101, Life Safety Code 18.5.2 Heating, Ventilating, and Air-Conditioning18.5.2.2 Any heating device, other than a central heating plant, shall be designed and installed so that combustible material cannot be ignited by the device or its appurtenances, and the following requirements shall also apply:(1) If fuel-fired, such heating devices shall comply with the following:(a) They shall be chimney connected or vent connected.(b) They shall take air for combustion directly from outside.(c) They shall be designed and installed to provide for complete separation of the combustion system from the atmosphere of the occupied area.(2) Any heating device shall have safety features to immediately stop the flow of fuel and shut down the equipment in case of either excessive temperature or ignition failure. Based on observations and interviews, the facility failed to ensure gas-fired heating equipment was separated from combustible materials in 1 of 1 fuel-fired mechanical rooms, in accordance with NFPA 101, Life Safety Code, 2012 Edition, 18.5.2.2.The facility failed to store combustible materials in an area away from fuel-fired equipment.Although no actual harm has occurred, this deficiency could potentially affect future residents, leading to smoke inhalation and fire-related injuries if a fire occurs in this hazardous area due to stored combustible materials. Eight patients were present at the facility during the initial inspection.Findings include:Observations during the initial building orientation tour on 11/19/2025, between 10:20 a.m. and 11:00 a.m., revealed combustible materials, including approximately 20 boxes of heating and ventilation equipment filters, stored in the gas-fueled mechanical room 185. This room contained two 199,900 BTU each, domestic gas-fired water heaters. In an adjacent room open to the atmosphere, two large water heaters, also fueled by natural gas, were observed, designed to provide heat to the building.During interviews on 11/19/2025 at 10:45 a.m. and 4:20 p.m., the facility management director stated he was unaware that storing combustibles in the fuel-fired mechanical room was prohibited. He also noted the additional fire load could increase smoke and heat, potentially raising the risk of smoke inhalation and fire-related burns. He further stated they would remove the materials and store them in a room designated for combustible storage.”

“References:CFR 42, 418.110 (e) Standard: Building Safety. Except as otherwise provided in this section, the hospice must meet the applicable provisions and must proceed in accordance with the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6).(1) Chapters 7, 8, 12, and 13 of the adopted Health Care Facilities Code do not apply to a hospice.2010 NFPA 99 Health Care Facilities CodeChapter 4 Fundamentals4.1 Building System Categories. Building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code.4.1.1 Category 1. Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers shall be designed to meet system Category 1 requirements as defined in this code.4.1.2 Category 2. Facility systems in which failure of such equipment is likely to cause minor injury to patients or caregivers shall be designed to meet system Category 2 requirements as defined in this code.4.1.3 Category 3. Facility systems in which failure of such equipment is not likely to cause injury to patients or caregivers, but can cause patient discomfort, shall be designed to meet system Category 3 requirements as defined in this code.4.1.4 Category 4. Facility systems in which failure of such equipment would have no impact on patient care shall be designed to meet system Category 4 requirements as defined in this code.4.2 Risk Assessment. Categories shall be determined by following and documenting a defined risk assessment procedure.4.3 Application. The Category definitions in Chapter 4 shall apply to Chapters 5 through 11. Based on record review and interview, the facility failed to provide the required NFPA 99 Health Facilities Code Risk assessment for the inpatient unit’s service area, required by CFR 42, 418.110, and NFPA 99 4.1.The facility did not have a patient-focused written Risk Assessment, as required by following and documenting a defined risk assessment procedure. Building systems in health care facilities, including long-term care facilities, are designed to meet Category 1 through Category 4 requirements in NFPA 99, as detailed, to support the level of care provided.This deficient practice could affect future patients during a power outage or a building equipment emergency if the level of care available at the facility is not clearly defined. A distinction must be made between what qualifies as life support and what qualifies as palliative care. Unprepared staff or inadequate building systems designed for the level of care provided may cause delays, leading to distress and physical injuries.There were eight patients at the facility during the license renewal inspection.Findings included:Record reviews on 11/19/2025 revealed that the facility did not have a written NFPA 99 patient care risk assessment conducted by qualified personnel who evaluated the medical gas and vacuum systems, electrical systems, IT and communication systems, heating and ventilating equipment, or electrical equipment.During an interview on 11/19/2025 at 2:30 p.m., the Administrator stated they did not realize they were required to conduct an NFPA 99 risk assessment and that they understood the need for one to align the level of care provided with the category of the facility’s existing building systems. At 4:10 p.m. on 11/19/2025, the administrator provided a document titled “Hendrick Hospice Mechanical Unit Inventory” that included NFPA 99 risk categories assigned to mechanical systems such as building heating equipment (boilers and hot water pumps), rooftop air conditioning and air handling units, medical vacuum pumps, exhaust fans, etc. The standby generator is erroneously classified as a category one system, which implies the use of life support systems.”

“References:2012 NFPA 101, Life Safety Code LSC18.2.9 Emergency Lighting.18.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.18.2.9.2 Buildings equipped with, or in which patients require the use of, life-support systems (see 18.5.1.3) shall have emergency lighting equipment supplied by the life safety branch of the electrical system as described in NFPA 99, Health Care Facilities Code18.5.1 Utilities.18.5.1.1 Utilities shall comply with the provisions of Section 9.1.18.5.1.2 Power for alarms, emergency communications systems, and illumination of generator set locations shall be in accordance with the essential electrical system requirements of NFPA 99, Health Care Facilities Code. 18.5.1.3 Any health care occupancy, as indicated in 18.1.1.1.4, that normally uses life-support devices shall have electrical systems designed and installed in accordance with NFPA 99, Health Care Facilities Code, unless the facility uses life-support equipment for emergency purposes only.2012 NFPA 99 Health Care Facilities Code3.3.48 Essential Electrical System. A system comprised of alternate sources of power and all connected distribution systems and ancillary equipment, designed to ensure continuity of electrical power to designated areas and functions of a health care facilityduring disruption of normal power sources, and also to minimize disruption within the internal wiring system. (ELS)6.5.2.2.2 Life Safety Branch.6.5.2.2.2.1 The life safety and critical branches 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) Alarm and alerting systems, including the following:(a) Fire alarms(b) Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 5(4) Communications systems, where used for issuing instructions during emergency conditions(5) Sufficient lighting in dining and recreation areas to provide illumination to exit ways of a minimum of 5 ft-candles(6) Task illumination and select receptacles at the generator set location(7) Elevator cab lighting, control, communications, and signal systems6.5.2.2.2.2 No functions, other than those listed in 6.5.2.2.2.1(1) through (7), shall be connected to the life safety.6.5.2.2.3 Equipment Branch.6.5.2.2.3.1 General. (A) The equipment branch shall be installed and connectedto the alternate power source such that equipment listed in 6.5.2.2.3.2 is automatically restored to operation at appropriate time-lag intervals following the restoration of the life safety and equipment branches to operation.(B) The equipment branch arrangement shall also provide for the additional connection of equipment listed in 6.5.2.2.3.3.6.5.2.2.3.2 AC Equipment for Non-delayed-Automatic Connection.Generator accessories including, but not limited to, the transfer fuel pump, electrically operated louvers, and other generator accessories essential for generator operation shall be arranged for automatic connection to the alternate power source.6.5.2.2.3.3 Delayed-Automatic Connections to Equipment Branch. The following equipment shall be permitted to be connected to the equipment branch and shall be arranged for delayed-automatic connection to the alternate power source:(1) Task illumination and select receptacles in the following:(a) Patient care rooms(b) Medication preparation areas(c) Pharmacy dispensing areas(d) Nurses’ stations (unless adequately lighted by corridor luminaires)(2) Supply, return, and exhaust ventilating systems for airborne infectious isolation rooms(3) Sump pumps and other equipment required to operate for the safety of major apparatus and associated control systems and alarms(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 hood6.5.2.2.3.4 Delayed-Automatic or Manual Connections to Equipment Branch. The equipment in 6.5.2.2.3.4(A) and 6.5.2.2.3.4(B) shall be permitted to be connected to the equipment branch and shall be arranged for either delayed-automatic or manual connection to the alternate power source.(A) Heating Equipment to Provide Heating for General Patient Rooms. Heating of general patient rooms during disruption of the normal source shall not be required under any of the following conditions:(1) The outside design temperature is higher than −6.7°C (+20°F).(2) The outside design temperature is lower than −6.7°C (+20°F) and, where a selected room(s) is provided for the needs of all confined patients, then only such room(s) need be heated.(3) The facility is served by a dual source of normal power. See A.6.4.1.1.1 for more information.(B) Elevator Service. In instances where interruptions of power would result in elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of passengers.(C) Optional Connections to the Equipment Branch. Additional illumination, receptacles, and equipment shall be permitted to be connected only to the equipment branch.(D) Multiple Systems. Where one switch serves multiple systems as permitted in 6.5.2.2, transfer for all loads shall be non-delayed automatic. Based on observations, interviews, and record reviews, the facility did not ensure that one of one emergency power systems (EPS) serving the building was wired in accordance with NFPA 99, Health Care Facilities Code, as referenced in NFPA 101, Life Safety Code, sections 18.2.9.2, 18.5.1.2, and 18.5.1.3.The facility did not connect the rooftop-mounted air-handling units to the “equipment” power branch of the essential electrical system.Although no actual harm has occurred, this deficiency could affect patients, families, and staff because EPS circuits dedicated to the life safety branch, as a priority, may become overloaded when mechanical equipment is powered off this electrical branch. This may delay quick evacuation in an emergency or postpone powering equipment needed to maintain operations during a power outage.Delayed Evacuation: An overloaded circuit powering life safety systems could cause failures in essential evacuation infrastructure (e.g., emergency lighting, fire alarm panels), hindering a quick and safe exit from the building. Operational Delays: Equipment necessary to maintain critical operations during an outage might fail to receive power, disrupting essential services (e.g., patient monitoring systems, communication devices). Eight patients were present at the facility during the initial inspection. Findings include:During a record review on 11/19/2025, it was revealed that the Hendrick Hospice Care Mechanical Utility Inventory risk assessment conducted by the facility assigned the facility’s emergency power generator a NFPA 99 Risk Category 1, indicating that electrical failure may cause “major injury or death of patients.” During a record review of the construction drawings for the facility in the afternoon on 11/19/2025, it was identified that an NFPA 99 Type 2 Essential Electrical System was installed.During observations on 11/19/2025 at 10:50 AM, the electrical panels of the emergency power system (EPS) were identified as “emergency” and “critical” power panels, consistent with the 1999 edition of NFPA 99, Standard for Health Care Facilities, Type 2 Systems.During observations on 11/20/2025 at 9:45 a.m., the emergency power panel HE2, 277/480V, was found to have rooftop HVAC units connected to circuits 2, 4, 6, and 8. Circuits 26, 28, and 30 are identified as “main breaker.”During an interview on 11/20/2025 at 9:48 a.m., the facilities director stated he was unaware that the life safety branch of the essential electrical system is limited to supplying power for lighting, receptacles, and equipment, as specified in NFPA 99, 6.5.2.2.2 Life Safety Branch. He said that the healthcare system’s engineer would be asked to verify the existing circuits on the life-safety EES panels and to get back to him with a resolution. He acknowledged this may delay quick evacuation in an emergency or postpone powering equipment needed to maintain operations during a power outage.”

“References: NFPA 99, Health Facilities Code, 2012 Edition 11.3.3 Storage for nonflammable gases with a total volume equal to or less than 8.5 m3 (300 ft3) shall comply with the requirements in 11.3.3.1 and 11.3.3.2. 11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:(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 Based on observation and interview, the facility failed to maintain a minimum distance of five feet between oxygen storage and combustible material in one of one Biohazard Storage Room (Room 178) according to NFPA 99, 11.3.2.3(2) as referred to by NFPA 99, 11.3.3. The facility failed to maintain a minimum distance of five feet between oxygen storage and combustible material. Failure to maintain a minimum distance of five feet between oxygen storage and combustibles in an interior space could negatively affect inpatient residents. This deficient practice could result in an accelerated spread of fire, which could cause fire and smoke related injuries to residents. Findings include: Observation on 11/19/2025 at 2:49 p.m., accompanied by Facility Compliance, revealed 14 “E” sized cylinders of oxygen inside the Biohazard Storage room, Room 178, located on the service hallway. Further observation revealed multiple boxes of combustible biohazard material stored less than 5 feet from the oxygen cylinders. In an interview on 11/20/2025 at 10:28 a.m. with Facility Compliance, when asked if he knew the requirement for combustible storage with oxygen cylinders, he related was aware of the requirement. When asked if he knew the oxygen cylinders had been stored less than 5 feet from the combustible material, he stated he was not aware prior to the survey. When asked how long the oxygen cylinders had been stored within 5 feet of the combustible material, he related he believed the oxygen had been stored less than 5 feet from the combustible material in the Biohazard room for approximately 2 to 3 months. When asked who was responsible for ensuring oxygen cylinders were not being stored within 5 feet of combustible material, he said the Compliance Department was responsible. The Facility Compliance acknowledged the failure could result in an accelerated spread of fire, which could cause fire and smoke related injuries to residents.”