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Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain/provide a valid two-hour fire rated occupancy separation between the Existing Health Care Occupancy and adjoining non-Health Care Occupancy in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff:
1.) Unprotected ductwork passed through the two-hour separation in four locations without dampers.
2.) The gaps between the wall and the ductwork above the ceiling voided a two-hour fire rating.
3.) The two-hour construction did not continue from outside wall to outside wall, or similar rated wall, as required to be continuous.
4.) There were unsealed penetrations through the drywall above the ceiling.
5.) There were various sized unsealed pipe, conduit and construction penetrations above the ceiling.
? NFPA 101 Section 19.1.2.1 reads, " Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
1.) They are not intended to serve health care occupants for purposes of housing, treatment, or customary access by patients incapable of self-preservation.
2.) They are separated from areas of health care occupancies by construction having a fire resistance rating of not less than 2 hours. "
The maintenance staff acknowledged the above items during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain the doors that protect the corridors in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, the corridor door to room #E101 did not positively latch into the doorframe.
? NFPA 101 Section 19.3.6.3.2 reads in part, " Doors shall be provided with a means suitable for keeping the door closed . . . "
The maintenance staff acknowledged the lack of properly functioning positive latching hardware during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain the one-hour fire resistive rating of vertical openings between floors in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, there was an unprotected vertical opening, a mechanical pipe chase, between the basement and the attic.
? NFPA 101 Section 19.3.1.1 reads, " Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating."
The maintenance staff acknowledged the unprotected vertical opening during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to provide proper hold open devices on corridor doors protecting vertical openings and hazardous areas in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, the corridor doors to various areas that are required to be automatic-closing did not have proper corridor detection or spot detection for the doorways. In the following areas it was observed the smoke detectors were not properly spaced in accordance with NFPA 72; this is not a complete list, the facility shall have detection properly installed where required:
1.) In the corridor by room #29 the location of the smoke detector exceeds the listed spacing for corridor detection.
2.) In the corridor by room #10 and #22 there were no system smoke detectors.
3.) In the corridor by #E-100 the smoke detector was mounted too close to a ceiling diffuser.
? NFPA 101 Section 19.3.4.1 reads, " 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. "
? NFPA 72 Section 2-3.6.6.2 reads, " Smoke detectors shall not be located directly in the airstream of supply registers.
? NFPA 101 Section 7.2.1.8.2 reads, " 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.
The maintenance staff acknowledged sporadic spacing of the smoke detectors during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain the smoke barriers in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, the smoke barrier wall above the cross-corridor doors had penetrations of various sizes through it; to include conduits, wire bundles and exhaust fan ductwork.
? NFPA 101 Section 19.3.7.3 reads in part, " Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour ... "
? NFPA 101 Section 8.3.2 reads in part, " Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor... " .
The maintenance staff acknowledged the penetrations in the smoke barrier during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain the door protecting the smoke barriers in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, the smoke barrier door in the attic was in the open position; the door was not self-closing or automatic closing.
? NFPA 101 Section 19.3.7.6 reads in part, " Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6 ... "
The maintenance staff acknowledged the open door through the smoke barrier in the attic during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain the separation of hazardous areas in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, the following rooms contained storage and/or combustible contents and the doors to the corridor did not have a self-closing or automatic-closing device; these rooms meet hazardous area definition guidance of NFPA 101 Section 19.3.2.1:
1.) Room #33 had storage similar to a janitor ' s closet.
2.) Room # 20 had storage similar to a central storage room.
3.) Room # 171 had storage similar to a clean linen room.
4.) Room # 18b had storage similar to a janitor ' s closet and activity storage room.
5.) Room # 19 had storage similar to a janitor ' s closet.
6.) Room # 23 had storage similar to a janitor ' s closet.
? NFPA 101 Section 19.3.2.1 reads in part, " . . . the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. " (For closing devices, see NFPA 101 Section 7.2.1.8.2)
The maintenance staff acknowledged the storage in the various rooms during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain exit access ready and accessible at all times in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff,

1.) The overall travel distance within surgery suite #176, with two intervening rooms, was 55-feet which exceeds the allowance of 50-feet maximum.
? NFPA 101 Section 19.2.1 reads, " ...Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Exception: As modified by 19.2.2 through 19.2.11. "
? NFPA 101 Section 19.2.5.8 reads, " Suites of rooms, other than patient sleeping rooms, shall be permitted to have one intervening room if the travel distance within the suite to the exit access door does not exceed 100 ft (30 m) and shall be permitted to have two intervening rooms where the travel distance within the suite to the exit access door does not exceed 50 ft (15 m). "
2.) The two exit doors of the exterior CT out building were not remotely located from each other; the trailer measured ~30-feet x 11-feet and the doors measured 9-foot 5-inches, these doors shall be greater than 15-feet apart if the out building remains unsprinklered and the doors shall be greater than 10-feet apart if the out building becomes sprinklered.
? NFPA 101 Section 19.2.4 reads, " Not less than two exits of the types described in 19.2.2.2 through 19.2.2.10, remotely located from each other, shall be provided for each floor or fire section of the building.. "
? NFPA 101 Section 7.5.1.4 reads in part, " Where two exits or exit access doors are required, they shall be placed at a distance from one another not less than one-half the length of the maximum overall diagonal dimension of the building or area to be served, measured in a straight line between the nearest edge of the exit doors or exit access doors. Where exit enclosures are provided as the required exits and are interconnected by not less than a 1- hour fire resistance-rated corridor, exit separation shall be permitted to be measured along the line of travel within the corridor.
Where more than two exits or exit access doors are required, at least two of the required exits or exit access doors shall be arranged to comply with the minimum separation distance requirement. The other exits or exit access doors shall be located so that if one becomes blocked, the others shall be available.
Exception No. 1: In buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, the minimum separation distance between two exits or exit access doors measured in accordance with 7.5.1.4 shall be not less than one-third the length of the maximum overall diagonal dimension of the building or area to be served.
3.) The two exterior exit doors from the CT out building required two actions to open the door; each door had a lever latch and a top lock.
? NFPA 101 Section 7.2.1.5.4 reads in part, " A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1:* Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
4.) There were magnetic locks installed on corridor egress exit doors by room #38, these locking devices did not meet delayed-egress or access-controlled requirements
? NFPA 101 Section 19.2.2.2.4 reads, " Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.)
Exception No. 2:* Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.
5.) The double corridor doors to the phone closet by room #21 and the double corridor doors to room #165 did not have separate doorframe latching hardware or automatic flush mount bolts.
? NFPA 101 Section 7.2.1.5.5 reads, " Where pairs of doors are required in a means of egress, each leaf of the pair shall be provided with its own releasing device. Devices that depend on the release of one door before the other shall not be used.
Exception: Where exit doors are used in pairs and approved automatic flush bolts are used, the door leaf equipped with the automatic flush bolts shall have no doorknob or surface-mounted hardware. The unlatching of any leaf shall not require more than one operation.
6.) The stairs from the corridor exit by room #167 was not continuous to public way.
? NFPA 101 Section 7.7.1 reads in part, " Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way ... "
The maintenance staff acknowledged the above items during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to provide fire alarm system components in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff:
1.) The fire alarm visual notification appliances were not properly spaced. The strobes in the following areas were not properly spaced in accordance with NFPA 72; this is not a complete list, the facility shall have visual notification properly installed where required:
a) Corridor #10 and the corridor by room #29 was without strobe coverage.
b) Surgical suite #176 was without proper strobe coverage.
? NFPA 101 Section 19.3.4.3.1 reads, "Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3.
Exception No. 1:* In lieu of audible alarm signals, visible alarm-indicating appliances shall be permitted to be used in critical care areas.
Exception No. 2: Where visual devices have been installed in patient sleeping areas in place of the audible alarm, they shall be permitted where accepted by the authority having jurisdiction. "
? NFPA 101 Section 9.6.3.7-5.2.2 reads, " Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
Exception No. 1: Areas not subject to occupancy by persons who are hearing impaired shall not be required to comply with the provisions for visible signals.
Exception No. 2: Visible-only signals shall be provided where specifically permitted in health care occupancies in accordance with the provisions of Chapters 18 and 19.
Exception No. 3: Existing alarm systems shall not be required to comply with the provision for visible signals.
Exception No. 4: Visible signals shall not be required in lodging or rooming houses in accordance with the provisions of Chapter 26. "
2.) The power supply to the magnetic lock at the exit by room # 38 did not release when the primary power to the FACU was shut off.
? NFPA 101 Section 19.3.4.1 reads, "General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. "
? NFPA 101 Section 9.6.1.4 reads, " 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 Section 3-9.7.1 reads, " Any device or system intended to actuate the locking or unlocking of exits shall be connected to the fire alarm system serving the protected premises. "
? NFPA 72 Section 3-9.7.2 reads, " All exits connected in accordance with 3-9.7.1 shall unlock upon receipt of any fire alarm signal by means of the fire alarm system serving the protected premises.
Exception: Where otherwise required or permitted by the authority having jurisdiction or other codes. "
? NFPA 72 Section 3-9.7.3 reads, " All exits connected in accordance with 3-9.7.1 shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply shall not be utilized to maintain these doors in the locked condition. "
3.) The elevator hoistway had a smoke detector at the top while there was no fire sprinkler protection at the top or bottom of the hoistway.
? NFPA 101 Section 9.1.6 reads, " Smoke detectors shall not be installed in elevator hoistways.
Exception No. 1: Where the top of the elevator hoistway is protected by automatic sprinklers.
Exception No. 2: Where a smoke detector is installed to activate the elevator hoistway smoke relief equipment."
The maintenance staff acknowledged the above items during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to provide an automatic fire sprinkler system in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff:
1.) The facility was not fully sprinklered throughout in accordance with NFPA 13; this is not a complete list, the facility shall have be fully sprinklered throughout where required:
a) Area by rooms #46 and #48 had no fire sprinkler protection.
b) The phone closet by room #21 had no fire sprinkler protection.
c) The CT out building and the gas meter housing had no fire sprinkler protection.
d) The exterior canopy by the ambulance entrance, the exit by room #167 and the exterior canopy by room #309 had no fire sprinkler protection.
? NFPA 101 Section 19.3.5.1 reads, " Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered " .
? NFPA 101 Section 9.1.6 reads in part, " Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2.. "
? NFPA 101 Section 9.7.1.1 reads, " 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.
2.) The elevator hoistway containing a hydraulic elevator did not have a sprinkler head at the bottom of the hoistway.
? NFPA 13 Section 5-13.6.1 reads, " Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit.
Exception: For enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids, the sprinklers at the bottom of the shaft are not required. "
The maintenance staff acknowledged the above items during the onsite survey.

Based on observation, record review and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to supervise all control valves for the fire sprinkler system in accordance with NFPA 101. The following evidenced this:
During the review of the facility records with the maintenance staff, documentation was not provided to show five of the control valves on antifreeze loops of the fire sprinkler system had electronic supervision; unsupervised control valves were observed during the onsite survey.
? NFPA 101 Section 9.7.2.1 reads, "Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility. "
The maintenance staff acknowledged unsupervised control valves during the onsite survey.

Based on observation, record review and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 101. The following evidenced this:
1.) During the walkthrough of the facility with the maintenance staff:
a) Fire sprinkler heads were installed in the following locations where the water discharge pattern of the sprinkler head was obstructed:
i. One of the fire sprinkler heads in room #42b was obstructed by server equipment.
ii. In rooms #18a and 18b construction created an alcove which obstructed the waterflow.
iii. In room #175 and room #173 the sprinkler head was obstructed by a light fixture.
iv. In room #47 the sprinkler head was obstructed by electrical conduit.
? NFPA 25 Section 2-2.1.2 reads, " Unacceptable obstructions to spray patterns shall be corrected. "
b) There were quick response and standard response sprinkler heads in the same sprinkler compartment in the following locations:
i. The corridor by room #182 had 4 standard response and 1 quick response sprinkler heads.
ii. Room #18a had 3 standard response and 1 quick response sprinkler heads.
iii. Room #17a had 1 standard response and 1 quick response sprinkler heads, that could be verified through the light panel of the locked door.
iv. The corridor by room #162 had standard response and quick response sprinkler heads.
v. Room #44 had 1 standard response and 3 quick response sprinkler heads.
? NFPA 13 Section 7-2.3.2.4 reads in part, " . . . Where quick-response sprinklers are installed, all sprinklers within a compartment shall be of the quick response type . . . "
c) There were non-system components supported from or resting on the fire sprinkler piping in rooms #45 and #48; additionally, the facility shall properly support the sprinkler piping in room #48 or submit the modulus to show the trapeze used will provide proper support of the fire sprinkler system.
? NFPA 13 Section 6-1.1.5 reads, " Sprinkler piping or hangers shall not be used to support non-system components. "
d) The pendant fire sprinkler head in room #27 was damaged; the deflector was missing from the bottom of the sprinkler head. Additionally, the upright sidewall fire sprinkler head at the bottom of the stairs by room # 45 was in the wrong orientation and the concealed heads in the OR appeared to have tape across the cover plate.
? NFPA 25 Section 2-2.1.1 reads in part, " 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. "
e) One of sprinkler heads in room #48 and the sprinkler head above the ice machine in the alcove by room #169 were located less than 4-inches from the sidewall.
? NFPA 13 Section 5-6.3.3 reads, " Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall. "
f) The support for the fire sprinkler piping in room #33 was no longer intact.
? NFPA 25 Section 2-2.3 reads in part, "Hangers and Seismic Braces. Sprinkler pipe hangers and seismic braces shall be inspected annually from the floor level. Hangers and seismic braces shall not be damaged or loose. Hangers and seismic braces that are damaged or loose shall be replaced or refastened. . . . "
g) Drop ceiling tiles were missing, damaged or not in place in various locations; the lack of a solid surface for heat to gather can delay fire sprinkler response. An incomplete drop ceiling was observed in rooms #18a, #30, #32, #33, #37, #42b and #163; this is not a complete list, the facility shall maintain the drop ceiling tiles where required:
? NFPA 13 Section 5-6.4.1.1 reads, " Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm).
Exception: Ceiling-type sprinklers (concealed, recessed, and flush types) shall be permitted to have the operating element above the ceiling and the deflector located nearer to the ceiling where installed in accordance with their listing "
? NFPA 13 Section 1-4.6 reads, "Construction Definitions.
Obstructed Construction.* Panel construction and other construction where beams, trusses, or other members impede heat flow or water distribution in a manner that materially affects the ability of sprinklers to control or suppress a fire.
? Unobstructed Construction.* Construction where beams, trusses, or other members do not impede heat flow or water distribution in a manner that materially affects the ability of sprinklers to control or suppress a fire. Unobstructed construction has horizontal structural members that are not solid, where the openings are at least 70 percent of the cross-section area and the depth of the member does not exceed the least dimension of the openings, or all construction types where the spacing of structural members exceeds 71/2 ft (2.3 m) on center. "
h) Ordinary temperature fire sprinkler heads were located within 12-inches of ceiling diffusers in rooms #175, #175 X-ray and #160, ordinary temperature sprinkler heads are not allowed within 12-inches of a ceiling diffuser; this is not a complete list, the facility shall maintain the sprinkler heads of proper temperature ratings where required:
? NFPA 13 Section 5-3.1.4.1 reads in part, " Ordinary-temperature-rated sprinklers shall be used throughout buildings ... "
? NFPA 13 Section 5-3.1.4.2 reads in part, " The following practices shall be observed to provide sprinklers of other than ordinary temperature classification unless other temperatures are determined or unless high-temperature sprinklers are used throughout ... "
? NFPA 13 Table 5-3.1.4.2(a)(a)3 reads in part, " ...Intermediate Degree Rating - Diffuser - Downward discharge: Cylinder with 1 ft 0 in. radius from edge extending 1 ft 0 in. below and 2 ft 6 in. above ... "
i) Sprinkler heads were located too close to each other in room #39, the sprinkler heads were located 5-foot 3-inches on center from each other.
? NFPA 13 Section 5-6.3.4 reads, " Sprinklers shall be spaced not less than 6 ft (1.8 m) on center. "
j) The fire sprinkler head in room #19b was located 10-foot 6-inches off the sidewall.
? NFPA 13 Section 5-6.3.2.1reads, " The distance from sprinklers to walls shall not exceed one-half of the allowable distance between sprinklers as indicated in Tables 5-6.2.2(a) through (d). The distance from the wall to the sprinkler shall be measured perpendicular to the wall. Where walls are angled or irregular, the maximum horizontal distance between a sprinkler and any point of floor area protected by that sprinkler shall not exceed 0.75 times the allowable distance permitted between sprinklers, provided the maximum perpendicular distance is not exceeded.
Exception: *Within small rooms as defined in 1-4.2, sprinklers shall be permitted to be located not more than 9 ft (2.7 m) from any single wall. Sprinkler spacing limitations of 5-6.3 and area limitations of Table 5-6.2.2(a) shall not be exceeded."
2.) During the review of the facility records with the maintenance staff, documentation was not provided to show:
a) Quarterly functional testing of the six waterflow devices.
? NFPA 25 Section 9-2.7 reads, " All waterflow alarms shall be tested quarterly in accordance with the manufacturer ' s instructions. "
b) Semiannual testing of the three tamper devices; documentation provided showed only two tamper devices were tested.
? NFPA 25 Section 9-3.4.3 reads, " Valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve ' s normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved one-fifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position. "
c) Appropriate manufacturer ' s literature was not available to show the thermal expansion tank in the stairway by room #17 was listed for use as installed in the antifreeze loop of the sprinkler system.
? NFPA 13 Section 3-1.1 reads, " All materials and devices essential to successful system operation shall be listed. "
The maintenance staff acknowledged the above items during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to provide/maintain the portable fire extinguishers in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, a portable fire extinguisher was observed not mounted and sitting on the floor in room #42 and there was not an ABC (or similar) fire extinguisher provided in the kitchen; only a Class K was observed in the kitchen.
? NFPA 101 Section 19.3.5.6 reads, " Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1. "
? NFPA 101 Section 9.7.4.1 reads, " Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. "
? NFPA 10 Section 1-6.10 reads, " Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in.(10.2 cm). "
? NFPA 10 Section 3-1.2.4 reads, " Buildings having an occupancy hazard subject to Class B or Class C fires, or both, shall have a standard complement of Class A fire extinguishers for building protection, plus additional Class B or Class C fire extinguishers, or both. Where fire extinguishers have more than one letter classification (such as 2-A:20-B:C), they can be considered to satisfy the requirements of each letter class. "
Typically in addition to the Class K required by NFPA 96 for the UL-300 suppression system a Class B or ABC is installed in kitchens (See A-3-1.2 for commentary).
The maintenance staff acknowledged the above items during the onsite survey.

Based on observation, record review and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain fusible linked fire dampers in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, a fusible link fire damper was observed in room #30; during a review of the facility records with the maintenance staff, documentation was not provided to show six year functional testing of the fusible links for the fire dampers.
? NFPA 101 Section 19.5.2.1 reads in part, " Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 . . . "
? NFPA 101 Section 9.2.1 reads in part, " 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 . . . "
? NFPA 90A Section 3-4.7 reads, " 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. "
? CMS S&C-10-04-LSC reads in part, " ...This memorandum permits hospitals to apply the NFPA 6-year testing interval for fire and smoke dampers in hospital heating and ventilating systems, so long as the hospital ' s testing system conforms to the testing requirements under the 2007 edition of NFPA 80 and NFPA 105 ... "
The maintenance staff acknowledged the lack of testing documentation for the fusible links during the onsite survey.

Based on observation, record review and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to provide a Kitchen Hood Suppression System in accordance with NFPA 101. The following evidenced this:
1.) During the walkthrough of the facility with the maintenance staff:
a) The upblast hood was not hinged with a service hold-open retainer to permit inspection.
? NFPA 101 Section 19.3.2.6 reads in part, " Cooking facilities shall be protected in accordance with 9.2.3 ... "
? NFPA 101 Section 9.2.3 reads in part, " Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations ... "
? NFPA 96 Section 4-8.2.1 reads in part, " Rooftop terminations shall be arranged with or provided with the following: ... (e) A hinged upblast fan supplied with flexible weatherproof electrical cable and service hold-open retainer to permit proper inspection and cleaning that is listed for commercial cooking equipment ... "
b) The Kitchen Hood Suppression System exhaust ductwork had what appeared to be a fusible link fire damper obstructing the suppression system from protecting the exhaust duct.
? NFPA 96 Section 6-1 reads, "Dampers. Dampers shall not be installed in exhaust ducts or exhaust duct systems
Exception: Where specifically listed for such use or where required as part of a listed or approved device or system.
? NFPA 96 Section 7-1 reads, " Fire-extinguishing equipment for the protection of grease removal devices, hood exhaust plenums, and exhaust duct systems shall be provided. "
c) The Kitchen Hood Suppression System ductwork had clumps of grease in less accessible areas.
? NFPA 96 Section 8-3.1 reads in part, " . . . shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. . . "
? NFPA 96 Section 8-3.1.1 reads in part, " . . . if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned . . . "
2.) During the review of the facility records with the maintenance staff, documentation was not provided to show the ductwork had been cleaned throughout nor was there documentation to show areas of the ductwork that was inaccessible to clean as there are no access panels in the exhaust duct that is greater than 14-feet in length.
? NFPA 96 Section 8-3.1.2 reads in part, " a certificate showing date of inspection or cleaning shall be maintained on the premises . . . It shall also indicate areas not cleaned. "
The maintenance staff acknowledged the above items during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain the clear and usable width of the means of in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, there were two vending machines and combustible storage in the stairwell by room #45, combustible storage was also observed in the stairs by room #17 and combustible storage was observed in the vestibule by room #43.
? NFPA 101 Section 19.2.1 reads, "General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.
? NFPA 101 Section 7.1.10.1 reads, " 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.
The maintenance staff acknowledged the above items during the onsite survey.

Based on observation, record review and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to install loosely hanging fabrics in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, the blinds in room #167 did not have a tag displaying the flame resistance properties of the fabric and a banner measuring approximately 4-foot by 11-foot was observed in corridor #10; maintenance staff was unable to provide documentation to show the fabric was flame-retardant.
? NFPA 101 Section 19.7.5.1 reads in part, " Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1 . . . " .
? NFPA 101 Section 10.3.1 reads in part, " . . . draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant . . . "
The maintenance staff acknowledged the loose hanging fabrics during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain the storage of medical gases in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, two of the six compressed gas cylinders were not restrained in room #176 and the oxygen manifold/storage room had unprotected ductwork that voided the required separation; the facility shall maintain the available oxygen storage within the manifold/storage room to less than 20,000 cubic feet or additional separation from the structure shall be required.
? NFPA 101 Section 19.3.2.4 reads, " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. "
? NFPA 99 Section 4-3.1.1.2 (b) 3 reads, " The walls, floors, and ceilings of locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) separating the supply system location from other occupancies in a building shall have a fire resistance rating of at least 1 hour. This shall also apply to a common wall or walls of a supply system location attached to a building having other occupancy.
? NFPA 99 Section 2-2.11 reads, " Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
The maintenance staff acknowledged the unsecured tanks and the duct during the onsite survey.

Based on record review and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain the Medical Gas and Vacuum Systems in accordance with NFPA 101. The following evidenced this:
1.) During the review of the facility records with the maintenance staff, the documentation provided by the facility, from an independent contractor, indicated the following deficiencies; the facility was not able to provide documentation to show the correction of the below items from their last inspection report dated August 6, 2012:
a) " The master and zone alarm panels at the nurses station are not labeled with emergency contact information. "
b) " The vacuum exhaust discharge is located immediately outside the storage room door. The exhaust shall be located at least 10 feet from any door, window, air intake or other openings in the building. "
c) " The master alarm panels do not contain all the required alarm signals. There shall be a signal to monitor the contents of the reserve oxygen supply when or at a predetermined set point before the reserve header contents fall below one day ' s average supply. Also, the condition of the vacuum system ' s local alarms (lag in use, thermal shutdown) shall be monitored at the master alarm panels. "
d) " The " Bank In Use " lamps that identify which bank if in use or empty on the oxygen supply manifold are not functioning. "
e) " The oxygen zone valve outside the Nursery is missing its gauge, all zone valves shall contain a pressure indicator. "
? NFPA 101 Section 19.3.2.4 reads, " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. "
? NFPA 99 Section 4-3.4.1.1 reads in part, " ...The responsible facility authority shall review these inspection and testing records prior to the use of all systems. This responsible facility authority shall ensure that all findings and results of the inspection and testing have been successfully completed, and all documentation pertaining thereto shall be maintained on-site within the facility ... "
2.) During the walkthrough of the facility with the maintenance staff, it was observed that medical gas piping was passing through electrical switchgear room #47; medical gas piping is not allowed in switch gear rooms.
? NFPA 99 Section 4-5.1.2.10(a)13 reads, " Piping shall not be installed in kitchens or electrical switchgear rooms. "
The maintenance staff acknowledged the report and piping during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to provide anesthetizing locations in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff:
1) A smoke exhaust system, for the anesthetizing location, could not be located or tested as functional during this survey.
? NFPA 101 Section 19.3.2.3 reads, " Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. "
? NFPA 99 Section 5-4.1.2 reads, " Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion. "
2) The anesthetizing location did not have electric shock protection; documentation was not provided to show the anesthetizing location did not meet wet location definition of NFPA 99.
? NFPA 99 Section 3-3.2.1.2(f)1 reads in part, " Wet location patient care areas shall be provided with special protection against electric shock. This special protection shall be provided by a power distribution system that inherently limits the possible ground-fault current due to a first fault to a low value, without interrupting the power supply; or by a power distribution system in which the power supply is interrupted if the ground-fault current does, in fact, exceed a value of 6 mA ... "
The maintenance staff acknowledged the above items during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to install/maintain the level 1 Essential Electrical System (EES) generator, wiring and equipment in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff:
1) A remote manual stop station was not able to be located in the area of the exterior generator during the survey.
? NFPA 110 Section 3-5.5.6 reads, " All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. "
2) The derangement alarm for the EES generator was not able to be located during the survey.
? NFPA 110 Section 3-4.1.1.15 reads in part, " A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station ... ...Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. "
3) The emergency power supply system (EPSS) equipment shall not be in the same room as the normal electrical service.
? NFPA 110 Section 5-2.2 reads, " EPSS equipment shall not be installed in the same room where the normal electrical service equipment is installed.
Exception: Transfer switches shall be permitted to be installed in the normal electrical service room where twice the clearance required by Article 110.16(a) of NFPA 70, National Electrical Code, exists between equipment enclosures. "
The maintenance staff acknowledged the items above during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to install/maintain equipment and utilities in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance supervisor, the Type II clothes dryer exhaust duct was too close to combustible construction, had screws connecting the sections, was not properly supported and was run in single-wall pipe outdoors.
? NFPA 101 Section 19.5.1 reads in part, " Utilities shall comply with the provisions of Section 9.1 . . . "
? NFPA 101 Section 9.1.1 reads in part, " Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code, or NFPA 58, Liquefied Petroleum Gas Code . . . "
? NFPA 54 Section 6.4.5 (d) reads, " Exhaust ducts for Type 2 clothes dryers shall have a clearance of at least 6 in. (150 mm) to combustible material.
Exception: Exhaust ducts for Type 2 clothes dryers shall be permitted to be installed with reduced clearances to combustible material, provided the combustible material is protected as described in Table 6.2.3(b).. "
? NFPA 54 Section 6.4.4 (b) reads, " Ducts for exhausting clothes dryers shall not be assembled with screws or other fastening means that extend into the duct and that would catch lint and reduce the efficiency of the exhaust system. "
? NFPA 54 Section 7.7.6 reads, " All portions of single-wall metal pipe shall be supported for the design and weight of the material employed. "
? NFPA 54 Section 7.7.2 reads, " Uninsulated single-wall metal pipe shall not be used outdoors in cold climates for venting gas utilization equipment. "
The maintenance staff acknowledged the above items during the onsite survey.

Based on record review and staff interview during the course of the survey conducted on September 6-7 2012, the laboratory did not have required policies in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance supervisor, documentation was not provided to show emergency procedures for chemical spills in the laboratory.
? NFPA 101 Section 19.3.2.2 reads, "Laboratories. Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as a severe hazard shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.
? NFPA 99 Section 10-2.1.3.2 reads, " Emergency procedures shall be established for controlling chemical spills. "
The maintenance staff acknowledged the above items during the onsite survey.

Based on record review and staff interview during the course of the survey conducted on September 6-7 2012, the laboratory did not have required policies in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance supervisor, documentation was not provided to show continuing safety education for laboratory personnel.
? NFPA 101 Section 19.3.2.2 reads, "Laboratories. Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as a severe hazard shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.
? NFPA 99 Section 10-2.1.4.2 reads, " Continuing safety education and supervision shall be provided, incidents shall be reviewed monthly, and procedures shall be reviewed annually. "
The maintenance staff acknowledged the above items during the onsite survey.

Based on record review and staff interview during the course of the survey conducted on September 6-7 2012, the laboratory did not have required policies in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance supervisor, documentation was not provided to show fire exit drills specific to the laboratory were conducted.
? NFPA 101 Section 19.3.2.2 reads, "Laboratories. Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as a severe hazard shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.
? NFPA 101 Section 10-2.1.4.3 reads, " Fire exit drills shall be conducted at least quarterly. Drills shall be so arranged that each person shall be included at least annually.
The maintenance staff acknowledged the above items during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain the electrical wiring and equipment in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff:
1.) It was observed there was a flexible cord originating from an outlet inside the attic. This flexible cord then passed through an access of the wall of the attic to the exterior, ran across the roof of the structure and dropped down a side of the building to supply power to an irrigation timer.
? NFPA 101 Section 19.5.1 reads, " Utilities shall comply with the provisions of Section 9.1. "
? NFPA 101 Section 9.1.2 reads in part, " Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code . . . " .
? NFPA 70 Section 400-8 reads in part, " . . . flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure . . . " .
2.) A flexible cord passing through the drop ceiling in room #45.
? NFPA 70 Section 400-8 reads in part, " . . . flexible cords and cables shall not be used for the following: (2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors ... " .
3.) There were uncovered junction boxes up in the attic.
? NFPA 70 Section 300-11 reads in part, " Raceways, cable assemblies, boxes, cabinets, and fittings shall be securely fastened in place... "
4.) The working space to the electrical equipment panel in room #25 did not have the minimum required distances.
? NFPA 70 Section 110-26 (a) reads, " Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of (1), (2), and (3) or as required or permitted elsewhere in this Code. "
5.) There were power strips in use as an extension cord to vending machines in the corridor by room #162, to a fridge in room #175 and a multi-tap adaptor was in use to multiple appliances in room #29.
? NFPA 70 Section 400-8 reads in part, " . . . flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure . . . "
The maintenance staff acknowledged the above items during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain/provide a valid two-hour fire rated occupancy separation between the Existing Health Care Occupancy and adjoining non-Health Care Occupancy in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff:
1.) Unprotected ductwork passed through the two-hour separation in four locations without dampers.
2.) The gaps between the wall and the ductwork above the ceiling voided a two-hour fire rating.
3.) The two-hour construction did not continue from outside wall to outside wall, or similar rated wall, as required to be continuous.
4.) There were unsealed penetrations through the drywall above the ceiling.
5.) There were various sized unsealed pipe, conduit and construction penetrations above the ceiling.
? NFPA 101 Section 19.1.2.1 reads, " Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
1.) They are not intended to serve health care occupants for purposes of housing, treatment, or customary access by patients incapable of self-preservation.
2.) They are separated from areas of health care occupancies by construction having a fire resistance rating of not less than 2 hours. "
The maintenance staff acknowledged the above items during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain the doors that protect the corridors in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, the corridor door to room #E101 did not positively latch into the doorframe.
? NFPA 101 Section 19.3.6.3.2 reads in part, " Doors shall be provided with a means suitable for keeping the door closed . . . "
The maintenance staff acknowledged the lack of properly functioning positive latching hardware during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain the one-hour fire resistive rating of vertical openings between floors in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, there was an unprotected vertical opening, a mechanical pipe chase, between the basement and the attic.
? NFPA 101 Section 19.3.1.1 reads, " Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating."
The maintenance staff acknowledged the unprotected vertical opening during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to provide proper hold open devices on corridor doors protecting vertical openings and hazardous areas in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, the corridor doors to various areas that are required to be automatic-closing did not have proper corridor detection or spot detection for the doorways. In the following areas it was observed the smoke detectors were not properly spaced in accordance with NFPA 72; this is not a complete list, the facility shall have detection properly installed where required:
1.) In the corridor by room #29 the location of the smoke detector exceeds the listed spacing for corridor detection.
2.) In the corridor by room #10 and #22 there were no system smoke detectors.
3.) In the corridor by #E-100 the smoke detector was mounted too close to a ceiling diffuser.
? NFPA 101 Section 19.3.4.1 reads, " 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. "
? NFPA 72 Section 2-3.6.6.2 reads, " Smoke detectors shall not be located directly in the airstream of supply registers.
? NFPA 101 Section 7.2.1.8.2 reads, " 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.
The maintenance staff acknowledged sporadic spacing of the smoke detectors during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain the smoke barriers in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, the smoke barrier wall above the cross-corridor doors had penetrations of various sizes through it; to include conduits, wire bundles and exhaust fan ductwork.
? NFPA 101 Section 19.3.7.3 reads in part, " Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour ... "
? NFPA 101 Section 8.3.2 reads in part, " Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor... " .
The maintenance staff acknowledged the penetrations in the smoke barrier during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain the door protecting the smoke barriers in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, the smoke barrier door in the attic was in the open position; the door was not self-closing or automatic closing.
? NFPA 101 Section 19.3.7.6 reads in part, " Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6 ... "
The maintenance staff acknowledged the open door through the smoke barrier in the attic during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain the separation of hazardous areas in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, the following rooms contained storage and/or combustible contents and the doors to the corridor did not have a self-closing or automatic-closing device; these rooms meet hazardous area definition guidance of NFPA 101 Section 19.3.2.1:
1.) Room #33 had storage similar to a janitor ' s closet.
2.) Room # 20 had storage similar to a central storage room.
3.) Room # 171 had storage similar to a clean linen room.
4.) Room # 18b had storage similar to a janitor ' s closet and activity storage room.
5.) Room # 19 had storage similar to a janitor ' s closet.
6.) Room # 23 had storage similar to a janitor ' s closet.
? NFPA 101 Section 19.3.2.1 reads in part, " . . . the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. " (For closing devices, see NFPA 101 Section 7.2.1.8.2)
The maintenance staff acknowledged the storage in the various rooms during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain exit access ready and accessible at all times in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff,

1.) The overall travel distance within surgery suite #176, with two intervening rooms, was 55-feet which exceeds the allowance of 50-feet maximum.
? NFPA 101 Section 19.2.1 reads, " ...Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Exception: As modified by 19.2.2 through 19.2.11. "
? NFPA 101 Section 19.2.5.8 reads, " Suites of rooms, other than patient sleeping rooms, shall be permitted to have one intervening room if the travel distance within the suite to the exit access door does not exceed 100 ft (30 m) and shall be permitted to have two intervening rooms where the travel distance within the suite to the exit access door does not exceed 50 ft (15 m). "
2.) The two exit doors of the exterior CT out building were not remotely located from each other; the trailer measured ~30-feet x 11-feet and the doors measured 9-foot 5-inches, these doors shall be greater than 15-feet apart if the out building remains unsprinklered and the doors shall be greater than 10-feet apart if the out building becomes sprinklered.
? NFPA 101 Section 19.2.4 reads, " Not less than two exits of the types described in 19.2.2.2 through 19.2.2.10, remotely located from each other, shall be provided for each floor or fire section of the building.. "
? NFPA 101 Section 7.5.1.4 reads in part, " Where two exits or exit access doors are required, they shall be placed at a distance from one another not less than one-half the length of the maximum overall diagonal dimension of the building or area to be served, measured in a straight line between the nearest edge of the exit doors or exit access doors. Where exit enclosures are provided as the required exits and are interconnected by not less than a 1- hour fire resistance-rated corridor, exit separation shall be permitted to be measured along the line of travel within the corridor.
Where more than two exits or exit access doors are required, at least two of the required exits or exit access doors shall be arranged to comply with the minimum separation distance requirement. The other exits or exit access doors shall be located so that if one becomes blocked, the others shall be available.
Exception No. 1: In buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, the minimum separation distance between two exits or exit access doors measured in accordance with 7.5.1.4 shall be not less than one-third the length of the maximum overall diagonal dimension of the building or area to be served.
3.) The two exterior exit doors from the CT out building required two actions to open the door; each door had a lever latch and a top lock.
? NFPA 101 Section 7.2.1.5.4 reads in part, " A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Exception No. 1:* Egress doors from individual living units and guest rooms of residential occupancies shall be permitted to be provided with devices that require not more than one additional releasing operation, provided that such device is operable from the inside without the use of a key or tool and is mounted at a height not exceeding 48 in. (122 cm) above the finished floor. Existing security devices shall be permitted to have two additional releasing operations. Existing security devices other than automatic latching devices shall not be located more than 60 in. (152 cm) above the finished floor. Automatic latching devices shall not be located more than 48 in. (122 cm) above the finished floor.
4.) There were magnetic locks installed on corridor egress exit doors by room #38, these locking devices did not meet delayed-egress or access-controlled requirements
? NFPA 101 Section 19.2.2.2.4 reads, " Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.)
Exception No. 2:* Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.
5.) The double corridor doors to the phone closet by room #21 and the double corridor doors to room #165 did not have separate doorframe latching hardware or automatic flush mount bolts.
? NFPA 101 Section 7.2.1.5.5 reads, " Where pairs of doors are required in a means of egress, each leaf of the pair shall be provided with its own releasing device. Devices that depend on the release of one door before the other shall not be used.
Exception: Where exit doors are used in pairs and approved automatic flush bolts are used, the door leaf equipped with the automatic flush bolts shall have no doorknob or surface-mounted hardware. The unlatching of any leaf shall not require more than one operation.
6.) The stairs from the corridor exit by room #167 was not continuous to public way.
? NFPA 101 Section 7.7.1 reads in part, " Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way ... "
The maintenance staff acknowledged the above items during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to provide fire alarm system components in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff:
1.) The fire alarm visual notification appliances were not properly spaced. The strobes in the following areas were not properly spaced in accordance with NFPA 72; this is not a complete list, the facility shall have visual notification properly installed where required:
a) Corridor #10 and the corridor by room #29 was without strobe coverage.
b) Surgical suite #176 was without proper strobe coverage.
? NFPA 101 Section 19.3.4.3.1 reads, "Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3.
Exception No. 1:* In lieu of audible alarm signals, visible alarm-indicating appliances shall be permitted to be used in critical care areas.
Exception No. 2: Where visual devices have been installed in patient sleeping areas in place of the audible alarm, they shall be permitted where accepted by the authority having jurisdiction. "
? NFPA 101 Section 9.6.3.7-5.2.2 reads, " Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
Exception No. 1: Areas not subject to occupancy by persons who are hearing impaired shall not be required to comply with the provisions for visible signals.
Exception No. 2: Visible-only signals shall be provided where specifically permitted in health care occupancies in accordance with the provisions of Chapters 18 and 19.
Exception No. 3: Existing alarm systems shall not be required to comply with the provision for visible signals.
Exception No. 4: Visible signals shall not be required in lodging or rooming houses in accordance with the provisions of Chapter 26. "
2.) The power supply to the magnetic lock at the exit by room # 38 did not release when the primary power to the FACU was shut off.
? NFPA 101 Section 19.3.4.1 reads, "General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. "
? NFPA 101 Section 9.6.1.4 reads, " 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 Section 3-9.7.1 reads, " Any device or system intended to actuate the locking or unlocking of exits shall be connected to the fire alarm system serving the protected premises. "
? NFPA 72 Section 3-9.7.2 reads, " All exits connected in accordance with 3-9.7.1 shall unlock upon receipt of any fire alarm signal by means of the fire alarm system serving the protected premises.
Exception: Where otherwise required or permitted by the authority having jurisdiction or other codes. "
? NFPA 72 Section 3-9.7.3 reads, " All exits connected in accordance with 3-9.7.1 shall unlock upon loss of the primary power to the fire alarm system serving the protected premises. The secondary power supply shall not be utilized to maintain these doors in the locked condition. "
3.) The elevator hoistway had a smoke detector at the top while there was no fire sprinkler protection at the top or bottom of the hoistway.
? NFPA 101 Section 9.1.6 reads, " Smoke detectors shall not be installed in elevator hoistways.
Exception No. 1: Where the top of the elevator hoistway is protected by automatic sprinklers.
Exception No. 2: Where a smoke detector is installed to activate the elevator hoistway smoke relief equipment."
The maintenance staff acknowledged the above items during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to provide an automatic fire sprinkler system in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff:
1.) The facility was not fully sprinklered throughout in accordance with NFPA 13; this is not a complete list, the facility shall have be fully sprinklered throughout where required:
a) Area by rooms #46 and #48 had no fire sprinkler protection.
b) The phone closet by room #21 had no fire sprinkler protection.
c) The CT out building and the gas meter housing had no fire sprinkler protection.
d) The exterior canopy by the ambulance entrance, the exit by room #167 and the exterior canopy by room #309 had no fire sprinkler protection.
? NFPA 101 Section 19.3.5.1 reads, " Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered " .
? NFPA 101 Section 9.1.6 reads in part, " Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2.. "
? NFPA 101 Section 9.7.1.1 reads, " 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.
2.) The elevator hoistway containing a hydraulic elevator did not have a sprinkler head at the bottom of the hoistway.
? NFPA 13 Section 5-13.6.1 reads, " Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit.
Exception: For enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids, the sprinklers at the bottom of the shaft are not required. "
The maintenance staff acknowledged the above items during the onsite survey.

Based on observation, record review and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to supervise all control valves for the fire sprinkler system in accordance with NFPA 101. The following evidenced this:
During the review of the facility records with the maintenance staff, documentation was not provided to show five of the control valves on antifreeze loops of the fire sprinkler system had electronic supervision; unsupervised control valves were observed during the onsite survey.
? NFPA 101 Section 9.7.2.1 reads, "Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility. "
The maintenance staff acknowledged unsupervised control valves during the onsite survey.

Based on observation, record review and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 101. The following evidenced this:
1.) During the walkthrough of the facility with the maintenance staff:
a) Fire sprinkler heads were installed in the following locations where the water discharge pattern of the sprinkler head was obstructed:
i. One of the fire sprinkler heads in room #42b was obstructed by server equipment.
ii. In rooms #18a and 18b construction created an alcove which obstructed the waterflow.
iii. In room #175 and room #173 the sprinkler head was obstructed by a light fixture.
iv. In room #47 the sprinkler head was obstructed by electrical conduit.
? NFPA 25 Section 2-2.1.2 reads, " Unacceptable obstructions to spray patterns shall be corrected. "
b) There were quick response and standard response sprinkler heads in the same sprinkler compartment in the following locations:
i. The corridor by room #182 had 4 standard response and 1 quick response sprinkler heads.
ii. Room #18a had 3 standard response and 1 quick response sprinkler heads.
iii. Room #17a had 1 standard response and 1 quick response sprinkler heads, that could be verified through the light panel of the locked door.
iv. The corridor by room #162 had standard response and quick response sprinkler heads.
v. Room #44 had 1 standard response and 3 quick response sprinkler heads.
? NFPA 13 Section 7-2.3.2.4 reads in part, " . . . Where quick-response sprinklers are installed, all sprinklers within a compartment shall be of the quick response type . . . "
c) There were non-system components supported from or resting on the fire sprinkler piping in rooms #45 and #48; additionally, the facility shall properly support the sprinkler piping in room #48 or submit the modulus to show the trapeze used will provide proper support of the fire sprinkler system.
? NFPA 13 Section 6-1.1.5 reads, " Sprinkler piping or hangers shall not be used to support non-system components. "
d) The pendant fire sprinkler head in room #27 was damaged; the deflector was missing from the bottom of the sprinkler head. Additionally, the upright sidewall fire sprinkler head at the bottom of the stairs by room # 45 was in the wrong orientation and the concealed heads in the OR appeared to have tape across the cover plate.
? NFPA 25 Section 2-2.1.1 reads in part, " 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. "
e) One of sprinkler heads in room #48 and the sprinkler head above the ice machine in the alcove by room #169 were located less than 4-inches from the sidewall.
? NFPA 13 Section 5-6.3.3 reads, " Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall. "
f) The support for the fire sprinkler piping in room #33 was no longer intact.
? NFPA 25 Section 2-2.3 reads in part, "Hangers and Seismic Braces. Sprinkler pipe hangers and seismic braces shall be inspected annually from the floor level. Hangers and seismic braces shall not be damaged or loose. Hangers and seismic braces that are damaged or loose shall be replaced or refastened. . . . "
g) Drop ceiling tiles were missing, damaged or not in place in various locations; the lack of a solid surface for heat to gather can delay fire sprinkler response. An incomplete drop ceiling was observed in rooms #18a, #30, #32, #33, #37, #42b and #163; this is not a complete list, the facility shall maintain the drop ceiling tiles where required:
? NFPA 13 Section 5-6.4.1.1 reads, " Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm).
Exception: Ceiling-type sprinklers (concealed, recessed, and flush types) shall be permitted to have the operating element above the ceiling and the deflector located nearer to the ceiling where installed in accordance with their listing "
? NFPA 13 Section 1-4.6 reads, "Construction Definitions.
Obstructed Construction.* Panel construction and other construction where beams, trusses, or other members impede heat flow or water distribution in a manner that materially affects the ability of sprinklers to control or suppress a fire.
? Unobstructed Construction.* Construction where beams, trusses, or other members do not impede heat flow or water distribution in a manner that materially affects the ability of sprinklers to control or suppress a fire. Unobstructed construction has horizontal structural members that are not solid, where the openings are at least 70 percent of the cross-section area and the depth of the member does not exceed the least dimension of the openings, or all construction types where the spacing of structural members exceeds 71/2 ft (2.3 m) on center. "
h) Ordinary temperature fire sprinkler heads were located within 12-inches of ceiling diffusers in rooms #175, #175 X-ray and #160, ordinary temperature sprinkler heads are not allowed within 12-inches of a ceiling diffuser; this is not a complete list, the facility shall maintain the sprinkler heads of proper temperature ratings where required:
? NFPA 13 Section 5-3.1.4.1 reads in part, " Ordinary-temperature-rated sprinklers shall be used throughout buildings ... "
? NFPA 13 Section 5-3.1.4.2 reads in part, " The following practices shall be observed to provide sprinklers of other than ordinary temperature classification unless other temperatures are determined or unless high-temperature sprinklers are used throughout ... "
? NFPA 13 Table 5-3.1.4.2(a)(a)3 reads in part, " ...Intermediate Degree Rating - Diffuser - Downward discharge: Cylinder with 1 ft 0 in. radius from edge extending 1 ft 0 in. below and 2 ft 6 in. above ... "
i) Sprinkler heads were located too close to each other in room #39, the sprinkler heads were located 5-foot 3-inches on center from each other.
? NFPA 13 Section 5-6.3.4 reads, " Sprinklers shall be spaced not less than 6 ft (1.8 m) on center. "
j) The fire sprinkler head in room #19b was located 10-foot 6-inches off the sidewall.
? NFPA 13 Section 5-6.3.2.1reads, " The distance from sprinklers to walls shall not exceed one-half of the allowable distance between sprinklers as indicated in Tables 5-6.2.2(a) through (d). The distance from the wall to the sprinkler shall be measured perpendicular to the wall. Where walls are angled or irregular, the maximum horizontal distance between a sprinkler and any point of floor area protected by that sprinkler shall not exceed 0.75 times the allowable distance permitted between sprinklers, provided the maximum perpendicular distance is not exceeded.
Exception: *Within small rooms as defined in 1-4.2, sprinklers shall be permitted to be located not more than 9 ft (2.7 m) from any single wall. Sprinkler spacing limitations of 5-6.3 and area limitations of Table 5-6.2.2(a) shall not be exceeded."
2.) During the review of the facility records with the maintenance staff, documentation was not provided to show:
a) Quarterly functional testing of the six waterflow devices.
? NFPA 25 Section 9-2.7 reads, " All waterflow alarms shall be tested quarterly in accordance with the manufacturer ' s instructions. "
b) Semiannual testing of the three tamper devices; documentation provided showed only two tamper devices were tested.
? NFPA 25 Section 9-3.4.3 reads, " Valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve ' s normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved one-fifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position. "
c) Appropriate manufacturer ' s literature was not available to show the thermal expansion tank in the stairway by room #17 was listed for use as installed in the antifreeze loop of the sprinkler system.
? NFPA 13 Section 3-1.1 reads, " All materials and devices essential to successful system operation shall be listed. "
The maintenance staff acknowledged the above items during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to provide/maintain the portable fire extinguishers in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, a portable fire extinguisher was observed not mounted and sitting on the floor in room #42 and there was not an ABC (or similar) fire extinguisher provided in the kitchen; only a Class K was observed in the kitchen.
? NFPA 101 Section 19.3.5.6 reads, " Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1. "
? NFPA 101 Section 9.7.4.1 reads, " Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. "
? NFPA 10 Section 1-6.10 reads, " Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in.(10.2 cm). "
? NFPA 10 Section 3-1.2.4 reads, " Buildings having an occupancy hazard subject to Class B or Class C fires, or both, shall have a standard complement of Class A fire extinguishers for building protection, plus additional Class B or Class C fire extinguishers, or both. Where fire extinguishers have more than one letter classification (such as 2-A:20-B:C), they can be considered to satisfy the requirements of each letter class. "
Typically in addition to the Class K required by NFPA 96 for the UL-300 suppression system a Class B or ABC is installed in kitchens (See A-3-1.2 for commentary).
The maintenance staff acknowledged the above items during the onsite survey.

Based on observation, record review and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain fusible linked fire dampers in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, a fusible link fire damper was observed in room #30; during a review of the facility records with the maintenance staff, documentation was not provided to show six year functional testing of the fusible links for the fire dampers.
? NFPA 101 Section 19.5.2.1 reads in part, " Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 . . . "
? NFPA 101 Section 9.2.1 reads in part, " 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 . . . "
? NFPA 90A Section 3-4.7 reads, " 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. "
? CMS S&C-10-04-LSC reads in part, " ...This memorandum permits hospitals to apply the NFPA 6-year testing interval for fire and smoke dampers in hospital heating and ventilating systems, so long as the hospital ' s testing system conforms to the testing requirements under the 2007 edition of NFPA 80 and NFPA 105 ... "
The maintenance staff acknowledged the lack of testing documentation for the fusible links during the onsite survey.

Based on observation, record review and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to provide a Kitchen Hood Suppression System in accordance with NFPA 101. The following evidenced this:
1.) During the walkthrough of the facility with the maintenance staff:
a) The upblast hood was not hinged with a service hold-open retainer to permit inspection.
? NFPA 101 Section 19.3.2.6 reads in part, " Cooking facilities shall be protected in accordance with 9.2.3 ... "
? NFPA 101 Section 9.2.3 reads in part, " Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations ... "
? NFPA 96 Section 4-8.2.1 reads in part, " Rooftop terminations shall be arranged with or provided with the following: ... (e) A hinged upblast fan supplied with flexible weatherproof electrical cable and service hold-open retainer to permit proper inspection and cleaning that is listed for commercial cooking equipment ... "
b) The Kitchen Hood Suppression System exhaust ductwork had what appeared to be a fusible link fire damper obstructing the suppression system from protecting the exhaust duct.
? NFPA 96 Section 6-1 reads, "Dampers. Dampers shall not be installed in exhaust ducts or exhaust duct systems
Exception: Where specifically listed for such use or where required as part of a listed or approved device or system.
? NFPA 96 Section 7-1 reads, " Fire-extinguishing equipment for the protection of grease removal devices, hood exhaust plenums, and exhaust duct systems shall be provided. "
c) The Kitchen Hood Suppression System ductwork had clumps of grease in less accessible areas.
? NFPA 96 Section 8-3.1 reads in part, " . . . shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. . . "
? NFPA 96 Section 8-3.1.1 reads in part, " . . . if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned . . . "
2.) During the review of the facility records with the maintenance staff, documentation was not provided to show the ductwork had been cleaned throughout nor was there documentation to show areas of the ductwork that was inaccessible to clean as there are no access panels in the exhaust duct that is greater than 14-feet in length.
? NFPA 96 Section 8-3.1.2 reads in part, " a certificate showing date of inspection or cleaning shall be maintained on the premises . . . It shall also indicate areas not cleaned. "
The maintenance staff acknowledged the above items during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain the clear and usable width of the means of in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, there were two vending machines and combustible storage in the stairwell by room #45, combustible storage was also observed in the stairs by room #17 and combustible storage was observed in the vestibule by room #43.
? NFPA 101 Section 19.2.1 reads, "General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.
? NFPA 101 Section 7.1.10.1 reads, " 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.
The maintenance staff acknowledged the above items during the onsite survey.

Based on observation, record review and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to install loosely hanging fabrics in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, the blinds in room #167 did not have a tag displaying the flame resistance properties of the fabric and a banner measuring approximately 4-foot by 11-foot was observed in corridor #10; maintenance staff was unable to provide documentation to show the fabric was flame-retardant.
? NFPA 101 Section 19.7.5.1 reads in part, " Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1 . . . " .
? NFPA 101 Section 10.3.1 reads in part, " . . . draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant . . . "
The maintenance staff acknowledged the loose hanging fabrics during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain the storage of medical gases in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff, two of the six compressed gas cylinders were not restrained in room #176 and the oxygen manifold/storage room had unprotected ductwork that voided the required separation; the facility shall maintain the available oxygen storage within the manifold/storage room to less than 20,000 cubic feet or additional separation from the structure shall be required.
? NFPA 101 Section 19.3.2.4 reads, " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. "
? NFPA 99 Section 4-3.1.1.2 (b) 3 reads, " The walls, floors, and ceilings of locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) separating the supply system location from other occupancies in a building shall have a fire resistance rating of at least 1 hour. This shall also apply to a common wall or walls of a supply system location attached to a building having other occupancy.
? NFPA 99 Section 2-2.11 reads, " Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
The maintenance staff acknowledged the unsecured tanks and the duct during the onsite survey.

Based on record review and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain the Medical Gas and Vacuum Systems in accordance with NFPA 101. The following evidenced this:
1.) During the review of the facility records with the maintenance staff, the documentation provided by the facility, from an independent contractor, indicated the following deficiencies; the facility was not able to provide documentation to show the correction of the below items from their last inspection report dated August 6, 2012:
a) " The master and zone alarm panels at the nurses station are not labeled with emergency contact information. "
b) " The vacuum exhaust discharge is located immediately outside the storage room door. The exhaust shall be located at least 10 feet from any door, window, air intake or other openings in the building. "
c) " The master alarm panels do not contain all the required alarm signals. There shall be a signal to monitor the contents of the reserve oxygen supply when or at a predetermined set point before the reserve header contents fall below one day ' s average supply. Also, the condition of the vacuum system ' s local alarms (lag in use, thermal shutdown) shall be monitored at the master alarm panels. "
d) " The " Bank In Use " lamps that identify which bank if in use or empty on the oxygen supply manifold are not functioning. "
e) " The oxygen zone valve outside the Nursery is missing its gauge, all zone valves shall contain a pressure indicator. "
? NFPA 101 Section 19.3.2.4 reads, " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. "
? NFPA 99 Section 4-3.4.1.1 reads in part, " ...The responsible facility authority shall review these inspection and testing records prior to the use of all systems. This responsible facility authority shall ensure that all findings and results of the inspection and testing have been successfully completed, and all documentation pertaining thereto shall be maintained on-site within the facility ... "
2.) During the walkthrough of the facility with the maintenance staff, it was observed that medical gas piping was passing through electrical switchgear room #47; medical gas piping is not allowed in switch gear rooms.
? NFPA 99 Section 4-5.1.2.10(a)13 reads, " Piping shall not be installed in kitchens or electrical switchgear rooms. "
The maintenance staff acknowledged the report and piping during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to provide anesthetizing locations in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff:
1) A smoke exhaust system, for the anesthetizing location, could not be located or tested as functional during this survey.
? NFPA 101 Section 19.3.2.3 reads, " Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. "
? NFPA 99 Section 5-4.1.2 reads, " Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically vent smoke and products of combustion. "
2) The anesthetizing location did not have electric shock protection; documentation was not provided to show the anesthetizing location did not meet wet location definition of NFPA 99.
? NFPA 99 Section 3-3.2.1.2(f)1 reads in part, " Wet location patient care areas shall be provided with special protection against electric shock. This special protection shall be provided by a power distribution system that inherently limits the possible ground-fault current due to a first fault to a low value, without interrupting the power supply; or by a power distribution system in which the power supply is interrupted if the ground-fault current does, in fact, exceed a value of 6 mA ... "
The maintenance staff acknowledged the above items during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to install/maintain the level 1 Essential Electrical System (EES) generator, wiring and equipment in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff:
1) A remote manual stop station was not able to be located in the area of the exterior generator during the survey.
? NFPA 110 Section 3-5.5.6 reads, " All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building. "
2) The derangement alarm for the EES generator was not able to be located during the survey.
? NFPA 110 Section 3-4.1.1.15 reads in part, " A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station ... ...Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. "
3) The emergency power supply system (EPSS) equipment shall not be in the same room as the normal electrical service.
? NFPA 110 Section 5-2.2 reads, " EPSS equipment shall not be installed in the same room where the normal electrical service equipment is installed.
Exception: Transfer switches shall be permitted to be installed in the normal electrical service room where twice the clearance required by Article 110.16(a) of NFPA 70, National Electrical Code, exists between equipment enclosures. "
The maintenance staff acknowledged the items above during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to install/maintain equipment and utilities in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance supervisor, the Type II clothes dryer exhaust duct was too close to combustible construction, had screws connecting the sections, was not properly supported and was run in single-wall pipe outdoors.
? NFPA 101 Section 19.5.1 reads in part, " Utilities shall comply with the provisions of Section 9.1 . . . "
? NFPA 101 Section 9.1.1 reads in part, " Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code, or NFPA 58, Liquefied Petroleum Gas Code . . . "
? NFPA 54 Section 6.4.5 (d) reads, " Exhaust ducts for Type 2 clothes dryers shall have a clearance of at least 6 in. (150 mm) to combustible material.
Exception: Exhaust ducts for Type 2 clothes dryers shall be permitted to be installed with reduced clearances to combustible material, provided the combustible material is protected as described in Table 6.2.3(b).. "
? NFPA 54 Section 6.4.4 (b) reads, " Ducts for exhausting clothes dryers shall not be assembled with screws or other fastening means that extend into the duct and that would catch lint and reduce the efficiency of the exhaust system. "
? NFPA 54 Section 7.7.6 reads, " All portions of single-wall metal pipe shall be supported for the design and weight of the material employed. "
? NFPA 54 Section 7.7.2 reads, " Uninsulated single-wall metal pipe shall not be used outdoors in cold climates for venting gas utilization equipment. "
The maintenance staff acknowledged the above items during the onsite survey.

Based on record review and staff interview during the course of the survey conducted on September 6-7 2012, the laboratory did not have required policies in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance supervisor, documentation was not provided to show fire exit drills specific to the laboratory were conducted.
? NFPA 101 Section 19.3.2.2 reads, "Laboratories. Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as a severe hazard shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.
? NFPA 101 Section 10-2.1.4.3 reads, " Fire exit drills shall be conducted at least quarterly. Drills shall be so arranged that each person shall be included at least annually.
The maintenance staff acknowledged the above items during the onsite survey.

Based on observation and staff interview during the course of the survey conducted on September 6-7 2012, it was determined the facility failed to maintain the electrical wiring and equipment in accordance with NFPA 101. The following evidenced this:
During the walkthrough of the facility with the maintenance staff:
1.) It was observed there was a flexible cord originating from an outlet inside the attic. This flexible cord then passed through an access of the wall of the attic to the exterior, ran across the roof of the structure and dropped down a side of the building to supply power to an irrigation timer.
? NFPA 101 Section 19.5.1 reads, " Utilities shall comply with the provisions of Section 9.1. "
? NFPA 101 Section 9.1.2 reads in part, " Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code . . . " .
? NFPA 70 Section 400-8 reads in part, " . . . flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure . . . " .
2.) A flexible cord passing through the drop ceiling in room #45.
? NFPA 70 Section 400-8 reads in part, " . . . flexible cords and cables shall not be used for the following: (2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors ... " .
3.) There were uncovered junction boxes up in the attic.
? NFPA 70 Section 300-11 reads in part, " Raceways, cable assemblies, boxes, cabinets, and fittings shall be securely fastened in place... "
4.) The working space to the electrical equipment panel in room #25 did not have the minimum required distances.
? NFPA 70 Section 110-26 (a) reads, " Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of (1), (2), and (3) or as required or permitted elsewhere in this Code. "
5.) There were power strips in use as an extension cord to vending machines in the corridor by room #162, to a fridge in room #175 and a multi-tap adaptor was in use to multiple appliances in room #29.
? NFPA 70 Section 400-8 reads in part, " . . . flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure . . . "
The maintenance staff acknowledged the above items during the onsite survey.