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Based on observation, staff interview, and record review facility staff failed to ensure movable walls had a flame spread rating. The facility census was 188.

1. Observation on 2/11/2020, during the facility tour, showed multiple movable partitions outside of the PACU. Observation showed the movable partitions did not have a spread rating.

Record review on 2/12/2020 of the manufacturer's specifications showed the movable partitions did not have a flame spread rating.

During an interview on 2/11/2020 at 11:10 A.M., the Director of Facilities Management said that he did not know if the movable partitions had a flame spread rating.

Interior Wall and Ceiling Finish
2012 EXISTING
Interior wall and ceiling finishes, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and have a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted.
10.2, 19.3.3.1, 19.3.3.2

Based on observation and facility staff interview, facility staff failed to ensure areas open to the corridor contain smoke detection per NFPA 72, National Fire Alarm and Signaling Code. The facility census was 188 .

Observations on 2/11/2020, during the facility tour, showed the following room/areas open to the corridor open to the designated exit corridor. Observation showed the rooms/areas did not have smoke detector coverage:

- 2nd floor family lounge;

- Registration vending area.

During an interview on 2/11/2020 at 12:38 P.M., the Director of Facilities Management confirmed the observations.

NFPA 101, 2012 edition states "Smoke detection systems are provided in spaces open to the corridors as required by 19.3.6.1".

19.3.4.1 General. Health care occupancies shall be provided
with a fire alarm system in accordance with Section 9.6.

Refer to NFPA 72, National Fire Alarm and Signaling Code, 2010 edition, sections 17.6.3 Location and Spacing and 17.6.3.3.1 Spacing for additional information.

Based on staff interview and record review, facility staff failed to inspect the wet sprinkler systems per NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition. The facility census was 188 .

Record review on 2/12/2020 did not show the following inspections:


-5 year internal pipe inspection for the sprinkler system covering the heart hospital, radiology, same day surgery, and registration.

During an interview on 2/12/2020 at 9:30 A.M., the Director of Facilities Management said that a five year internal pipe inspection was never conducted on the sprinkler systems covering the listed areas.

Refer to NFPA 25, Standard for the Inspection, Testing, and maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapters 5, 13 and 14 for additional information.