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Based on observation and staff interview, the facility failed to ensure ceiling structural steel was fire rated in 2 of 10 smoke compartments. The findings were:

Observation of the filter storeroom on 8/21/12 at 10:10 AM showed the steel I-beam was missing fire retardant material in a 12 inch by 9 inch section, leaving the steel exposed. At the time of the observation the plant operations manager reported he was aware the fire retardant material was required to be intact. He also reported that the fire retardant material was not routinely inspected to ensure the material was intact.

Based on observation and staff interview, the facility failed to ensure walls were smoke resistant in 1 of 10 smoke compartments. The findings were:

Observation of mechanical room #1001 on 8/21/12 at 9:21 AM showed a 2 inch by 6 inch unsealed pipe penetration. At the time of the observation the plant operations manager could not explain why the hole had not been notice and repaired during the quarterly safety inspections.

Based on observation and staff interview, the facility failed to ensure corridor doors were unobstructed in 1 of 10 smoke compartments. The findings were:

Observation on 8/21/12 between 2:30 PM and 3 PM showed the corridor doors to patient room #2225 and #2230 required excessive force to release the latch and to fully latch the doors into the door frames. At 2:55 PM that day the plant operations manager could not explain why these doors had not been noticed and repaired during the quarterly safety inspections.

Based on observation and staff interview, the facility failed to ensure the sprinkler system had complete coverage in 5 of 10 smoke compartments. The findings were:

Observation on 8/21/12 between 9:30 AM and 3 PM showed the following locations did not have complete sprinkler coverage:
a. The laundry washer room had a 4 foot by 2 foot unprotected area.
b. The kitchen had a 4 foot by 4 foot unprotected area near the freezer.
c. The kitchen service ramp had a 6 foot by 7 foot unprotected area.
d. The north stairwell first floor landing had a 8 foot by 5 foot unprotected area.
e. The autoclave equipment room measured 5 foot by 1 foot and did not have a sprinkler installed in the room.
f. The storage closet #2404 measured 64 inches by 12 inches and did not have a sprinkler installed in the room.
g. The corridor sprinkler near resident room #2500 was located 11 feet from the cross corridor smoke barrier doors. When the fire alarm is activated the next sprinkler head is obstructed and a 3 ? foot area is unprotected.
On 8/21/12 at 1:41 PM the plant operations manager could not explain why the heads had not been noticed and corrected during the annual sprinkler inspection completed by maintenance staff.

Reference NFPA 101, 2000 Edition, 18.3.5.1, 9.7.1.1, NFPA 13, 1999 Edition;
5-1.1 The requirements for spacing, location, and position of sprinklers are based on the following principles:
1) Sprinklers installed throughout the premises
2) Sprinkler located so as not to exceed maximum protection area per sprinkler
3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
5-5.3.1 Maximum Distance Between Sprinklers. The maximum distance permitted between sprinklers shall be based on the centerline distance between sprinklers on the branch line or on adjacent branch lines. The maximum distance shall be measured along the slope of the ceiling. The maximum distance permitted between sprinklers shall comply with the value indicated in the section for each type or style of sprinkler.
Table 5-6.2.2 (b) Protection Areas and Maximum Spacing (Standard Spray Upright/Standard Spray Pendent) for Ordinary Hazard
Construction Type ... ... ... .....All
System Type ... ... ... ... ..... ....All
Protection Area ... ... ... ... .....130 ft2
Spacing ... ... ... ... ... ... ..... ....15 ft

Based on observation and staff interview, the facility failed to ensure sprinkler heads were unobstructed in 2 of 10 smoke compartments. The findings were:

1. Observation of the laundry dryer room on 8/21/12 at 9:31 AM showed 1 of 3 sprinkler heads were obstructed by the ceiling mounted light fixture. The light fixture was located 10 inches away and 5 inches below the sprinkler head. At the time of the observation the plant operations manager could not explain why the obstructed head had not been noticed and corrected during the annual sprinkler inspection completed by maintenance staff.

2. Observation on 8/21/12 at 1:36 AM showed two corridor sprinkler heads had less than the allowed 1 inches clearance between the sprinkler deflector and ceiling. The deflectors were less than ? inch from the ceiling. At the time of the observation the plant operations manager could not explain why the heads had not been noticed and corrected during the annual sprinkler inspection completed by maintenance staff.

Reference NFPA 101, 2000 Edition, 18.3.5.1, 9.7.1.1, NFPA 13, 1999 Edition;
5-6.4.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. and a maximum of 12 in.
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (Standard Spray Upright/Standard Spray Pendent)
Distance from Maximum allowable
sprinkler to side distance from
of obstruction deflector above
bottom of obstruction
-------------------------------------------------------
Less than 1 ft ... ... ... ... ... ... ............. ....0
1 ft to less than 1 ft 6 in. ... ... ... ... ... ...2 ?
1 ft 6 in. to less than 2 ft .... ... ... ... ......3 ?
2 ft to less than 2 ft 6 in. ...... ... ... ... ...5 ?
2 ft 6 in. to less than 3 ft ... ... ... ...........7 ?
3 ft to less than 3 ft 6 in ... ... .... ... ... ...9 ?
3 ft 6 in. to less than 4 ft ... ... ... ... ... ...12
4 ft to less than 4 ft 6 in. ......................14

Based on observation and staff interview, the facility failed to ensure the oxygen manifold room was posted with a "No Smoking" sign. The findings were:

Observation of the oxygen manifold room #1013 on 8/21/12 at 10:17 AM showed the corridor door was not posted with a "No Smoking" sign. At the time of the observation the plant operations manager reported he was unaware the sign was required.

Based on observation and staff interview, the facility failed to ensure life safety branch equipment was properly separated in 1 of 10 smoke compartments. The findings were:

Observation of the electrical panel 1CL3 on 8/21/12 at 10:51 AM showed the panel was supplied with power from a critical branch automatic transfer switch. Further observation showed circuit #2 supplied power to the elevator cab lights which is life safety branch equipment. The elevator cab identification was hand written while the rest of the directory was printed. At the time of the observation the plant operations manager reported he was unsure when the elevator cab circuit was added.

Based on observation and staff interview, the facility failed to ensure temporary electrical wiring does not replace permanent fixed wiring in 4 of 10 smoke compartments. The findings were:

Observation of the electrical system on 8/21/12 between 11 AM and 2:30 PM showed the following locations had prohibited electrical adapters in use:
a. The lamp in the CEO's office was plugged into an extension cord.
b. The Steris 1E machine in sub sterile room #2316 was plugged into a 3-way adapter.
c. The computer in the blood lab was plugged into two surge protectors in-line.
d. The data tower in radiology #2616 was plugged into two surge protectors in-line.
On 8/21/12 at 11:12 AM the plant operations manager could not explain why the aforementioned adapters had not been noticed and removed during the semi-annual inspection.

Reference NFPA 101, 2000 Edition, 18.5.1.1, 9.1.2, NFPA 70, 1999 Edition;
400-8. Uses not permitted. Unless specifically permitted in section 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 ...
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces

Based on observation and staff interview, the facility failed to ensure ceiling structural steel was fire rated in 2 of 10 smoke compartments. The findings were:

Observation of the filter storeroom on 8/21/12 at 10:10 AM showed the steel I-beam was missing fire retardant material in a 12 inch by 9 inch section, leaving the steel exposed. At the time of the observation the plant operations manager reported he was aware the fire retardant material was required to be intact. He also reported that the fire retardant material was not routinely inspected to ensure the material was intact.

Based on observation and staff interview, the facility failed to ensure walls were smoke resistant in 1 of 10 smoke compartments. The findings were:

Observation of mechanical room #1001 on 8/21/12 at 9:21 AM showed a 2 inch by 6 inch unsealed pipe penetration. At the time of the observation the plant operations manager could not explain why the hole had not been notice and repaired during the quarterly safety inspections.

Based on observation and staff interview, the facility failed to ensure corridor doors were unobstructed in 1 of 10 smoke compartments. The findings were:

Observation on 8/21/12 between 2:30 PM and 3 PM showed the corridor doors to patient room #2225 and #2230 required excessive force to release the latch and to fully latch the doors into the door frames. At 2:55 PM that day the plant operations manager could not explain why these doors had not been noticed and repaired during the quarterly safety inspections.

Based on observation and staff interview, the facility failed to ensure the sprinkler system had complete coverage in 5 of 10 smoke compartments. The findings were:

Observation on 8/21/12 between 9:30 AM and 3 PM showed the following locations did not have complete sprinkler coverage:
a. The laundry washer room had a 4 foot by 2 foot unprotected area.
b. The kitchen had a 4 foot by 4 foot unprotected area near the freezer.
c. The kitchen service ramp had a 6 foot by 7 foot unprotected area.
d. The north stairwell first floor landing had a 8 foot by 5 foot unprotected area.
e. The autoclave equipment room measured 5 foot by 1 foot and did not have a sprinkler installed in the room.
f. The storage closet #2404 measured 64 inches by 12 inches and did not have a sprinkler installed in the room.
g. The corridor sprinkler near resident room #2500 was located 11 feet from the cross corridor smoke barrier doors. When the fire alarm is activated the next sprinkler head is obstructed and a 3 ? foot area is unprotected.
On 8/21/12 at 1:41 PM the plant operations manager could not explain why the heads had not been noticed and corrected during the annual sprinkler inspection completed by maintenance staff.

Reference NFPA 101, 2000 Edition, 18.3.5.1, 9.7.1.1, NFPA 13, 1999 Edition;
5-1.1 The requirements for spacing, location, and position of sprinklers are based on the following principles:
1) Sprinklers installed throughout the premises
2) Sprinkler located so as not to exceed maximum protection area per sprinkler
3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
5-5.3.1 Maximum Distance Between Sprinklers. The maximum distance permitted between sprinklers shall be based on the centerline distance between sprinklers on the branch line or on adjacent branch lines. The maximum distance shall be measured along the slope of the ceiling. The maximum distance permitted between sprinklers shall comply with the value indicated in the section for each type or style of sprinkler.
Table 5-6.2.2 (b) Protection Areas and Maximum Spacing (Standard Spray Upright/Standard Spray Pendent) for Ordinary Hazard
Construction Type ... ... ... .....All
System Type ... ... ... ... ..... ....All
Protection Area ... ... ... ... .....130 ft2
Spacing ... ... ... ... ... ... ..... ....15 ft

Based on observation and staff interview, the facility failed to ensure sprinkler heads were unobstructed in 2 of 10 smoke compartments. The findings were:

1. Observation of the laundry dryer room on 8/21/12 at 9:31 AM showed 1 of 3 sprinkler heads were obstructed by the ceiling mounted light fixture. The light fixture was located 10 inches away and 5 inches below the sprinkler head. At the time of the observation the plant operations manager could not explain why the obstructed head had not been noticed and corrected during the annual sprinkler inspection completed by maintenance staff.

2. Observation on 8/21/12 at 1:36 AM showed two corridor sprinkler heads had less than the allowed 1 inches clearance between the sprinkler deflector and ceiling. The deflectors were less than ? inch from the ceiling. At the time of the observation the plant operations manager could not explain why the heads had not been noticed and corrected during the annual sprinkler inspection completed by maintenance staff.

Reference NFPA 101, 2000 Edition, 18.3.5.1, 9.7.1.1, NFPA 13, 1999 Edition;
5-6.4.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. and a maximum of 12 in.
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (Standard Spray Upright/Standard Spray Pendent)
Distance from Maximum allowable
sprinkler to side distance from
of obstruction deflector above
bottom of obstruction
-------------------------------------------------------
Less than 1 ft ... ... ... ... ... ... ............. ....0
1 ft to less than 1 ft 6 in. ... ... ... ... ... ...2 ?
1 ft 6 in. to less than 2 ft .... ... ... ... ......3 ?
2 ft to less than 2 ft 6 in. ...... ... ... ... ...5 ?
2 ft 6 in. to less than 3 ft ... ... ... ...........7 ?
3 ft to less than 3 ft 6 in ... ... .... ... ... ...9 ?
3 ft 6 in. to less than 4 ft ... ... ... ... ... ...12
4 ft to less than 4 ft 6 in. ......................14

Based on observation and staff interview, the facility failed to ensure the oxygen manifold room was posted with a "No Smoking" sign. The findings were:

Observation of the oxygen manifold room #1013 on 8/21/12 at 10:17 AM showed the corridor door was not posted with a "No Smoking" sign. At the time of the observation the plant operations manager reported he was unaware the sign was required.

Based on observation and staff interview, the facility failed to ensure life safety branch equipment was properly separated in 1 of 10 smoke compartments. The findings were:

Observation of the electrical panel 1CL3 on 8/21/12 at 10:51 AM showed the panel was supplied with power from a critical branch automatic transfer switch. Further observation showed circuit #2 supplied power to the elevator cab lights which is life safety branch equipment. The elevator cab identification was hand written while the rest of the directory was printed. At the time of the observation the plant operations manager reported he was unsure when the elevator cab circuit was added.

Based on observation and staff interview, the facility failed to ensure temporary electrical wiring does not replace permanent fixed wiring in 4 of 10 smoke compartments. The findings were:

Observation of the electrical system on 8/21/12 between 11 AM and 2:30 PM showed the following locations had prohibited electrical adapters in use:
a. The lamp in the CEO's office was plugged into an extension cord.
b. The Steris 1E machine in sub sterile room #2316 was plugged into a 3-way adapter.
c. The computer in the blood lab was plugged into two surge protectors in-line.
d. The data tower in radiology #2616 was plugged into two surge protectors in-line.
On 8/21/12 at 11:12 AM the plant operations manager could not explain why the aforementioned adapters had not been noticed and removed during the semi-annual inspection.

Reference NFPA 101, 2000 Edition, 18.5.1.1, 9.1.2, NFPA 70, 1999 Edition;
400-8. Uses not permitted. Unless specifically permitted in section 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 ...
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces