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8.2.2.2, NFPA 101, LIFE SAFETY CODE
Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.

8.2.3.2.4.2, NFPA 101, LIFE SAFETY CODE
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on record review, interview, and observation the facility failed to ensure that fire barriers are properly protected and fire doors have self-closing devices installed.

Findings include:

Record review of facility floor plans during tour on 8/15/12 revealed the locations of fire barriers in the facility.

Interview during tour on 8/15/12 with Staff B (Maintenance Supervisor) and Staff C (Quality Assessment) confirmed the locations of two hour fire barriers.

Observation during tour on 8/15/12 between 1:00 p.m. and 2:00 p.m. with Staff B and Staff C revealed the following:

1. The fire barrier separating med surge from the area of the operating room and radiology has at least one pvc pipe greater than 2 inches in diameter that is not properly protected with a firestop collar.

2. The corridor leading to med surge near door 1900 has at least one unprotected penetration.

3. The fire barrier at the special care unit supply area has at least one unprotected penetration.

Interview during tour on 8/15/12 with Staff B and Staff C confirmed the findings.

18.3.1.1, NFPA 101, LIFE SAFETY CODE
Any vertical opening shall be enclosed or protected in accordance with 8.2.5.

8.2.5.2, NFPA 101, LIFE SAFETY CODE
Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

8.2.3.2.1, NFPA 101, LIFE SAFETY CODEDoor assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

1-6.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled fire doors shall be used.

2-3.1.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled door frames shall be used.

Based on observation and interview the facility failed to ensure that doors in enclosed stairwells have appropriately rated door leafs and frames.

Findings include:

Observation during tour on 8/16/12 at approximately 10:00 a.m. with Staff B (Maintenance Supervisor) and Staff C (Quality Assessment) revealed that the enclosed stairwell door assembly (door #1502) has a door frame with a label demonstrating that it has a 20 minute fire protection rating and the door leaf is not labeled.

Interview during tour on 8/16/12 with Staff B and Staff C at the time of discovery confirmed the findings.

18.3.7.6, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6.

8.3.4.1, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

A.8.3.4.1, NFPA 101, LIFE SAFETY CODE
The clearance for proper operation of smoke doors is defined as 1/8 in. (0.3 cm). For additional information on the installation of smoke-control door assemblies, see NFPA 105, Recommended Practice for the Installation of Smoke-Control Door Assemblies.

8.3.4.3, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

18.2.2.2.6, NFPA 101, LIFE SAFETY CODE
Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure (except boiler rooms, heater rooms, and mechanical equipment rooms) 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 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.

A.18.2.2.2.6, NFPA 101, LIFE SAFETY CODE
It is desirable to keep doors in exit passageways, stair enclosures, horizontal exits, smoke barriers, and required enclosures around hazardous areas closed at all times to impede the travel of smoke and fire gases. Functionally, however, this involves decreased efficiency and limits patient observation by the staff of an institution. To accommodate such needs, it is practical to presume that such doors will be kept open, even to the extent of employing wood chocks and other makeshift devices. Doors in exit passageways, horizontal exits, and smoke barriers should, therefore, be equipped with automatic hold-open devices activated by the methods described, regardless of whether the original installation of the doors was predicated on a policy of keeping them closed.

7.2.1.8.1, NFPA 101, LIFE SAFETY CODE
A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

7.2.1.8.2, NFPA 101, LIFE SAFETY CODE
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.

Based on record review, interview, and observation the facility failed to ensure that all smoke barrier doors have self-closing devices installed.

Findings include:

Record review of facility floor plans during tour on 8/15/12 revealed the locations of smoke barriers and smoke barrier doors in the facility.

Interview during tour on 8/15/12 with Staff B (Maintenance Supervisor) and Staff C (Quality Assessment) confirmed the locations of smoke barriers and smoke barrier doors.

Observation during tour on 8/15/12 between 12:30 p.m. and 3:00 p.m. revealed the following smoke barrier doors do not have self-closing devices installed:

1. Smoke barrier door #U325.

2. Smoke barrier door at registration.

3. Smoke barrier door #1303B at rehabilitation waiting area.

Interview during tour on 8/15/12 with Staff B and Staff C confirmed the findings at the time of discovery.

18.3.2.1, NFPA 101, LIFE SAFETY CODE
Hazardous Areas: Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.

8.4.1.3, NFPA 101, LIFE SAFETY CODE
Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

7.2.1.8.1, NFPA 101, LIFE SAFETY CODE
A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on observation and interview the facility failed to ensure that all hazardous areas have self-closing doors installed.

Findings include:

Observation during tour on 8/15/12 at approximately 1:40 p.m. with Staff B (Maintenance Supervisor) and Staff C (Quality Assessment) revealed that the door to the dirty utility room, door #U312, in the special care unit does not have a self-closing device installed.

Interview during tour on 8/15/12 with Staff B and Staff C at the time of discovery confirmed the findings.

18.3.5.1, NFPA 101, LIFE SAFETY CODE
Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

9.7.1.1, NFPA 101, LIFE SAFETY CODE
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.

9.7.5, NFPA 101, LIFE SAFETY CODE
Maintenance and Testing: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

5-1.1, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

5-6.5.1.2 Sprinklers shall be arranged to comply with... Table 5-6.5.1.2
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP):

Distance from Sprinklers to Side of Obstruction: Less than 1 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 0

Distance from Sprinklers to Side of Obstruction: 1 ft to less than 1 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 2-1/2

Distance from Sprinklers to Side of Obstruction: 1 ft 6 in. to less than 2 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 3-1/2

Distance from Sprinklers to Side of Obstruction: 2 ft to less than 2 ft 6 in.

Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 5-1/2

Distance from Sprinklers to Side of Obstruction: 2 ft 6 in. to less than 3 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 7-1/2

Distance from Sprinklers to Side of Obstruction: 3 ft to less than 3 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 9-1/2

Distance from Sprinklers to Side of Obstruction: 3 ft 6 in. to less than 4 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 12

Distance from Sprinklers to Side of Obstruction: 4 ft to less than 4 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 14

Distance from Sprinklers to Side of Obstruction: 4 ft 6 in. to less than 5 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 16-1/2

Distance from Sprinklers to Side of Obstruction: 5 ft and greater
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 18

2-2.1.1, NFPA 25, WATER-BASED FIRE PROTECTION SYSTEMS
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.

Based on observation and interview the facility failed to ensure that the spray patterns of sprinkler heads are not obstructed.

Findings include:

Observation during tour between 8/15/12 at approximately 11:15 a.m. and 8/16/12 at approximately 10:00 a.m. with Staff B (Maintenance Supervisor) and Staff C (Quality Assessment) revealed the following:

1. One sprinkler head with an obstructed spray pattern from a light fixture in the Emergency Department corridor. The deflector of the sprinkler head is approximately 5-1/4 inches from the ceiling, the thickness of the light fixture is approximately 6-3/4 inches from the ceiling, with the distance from the light fixture to the sprinkler head is approximately 10 inches apart.

2. At least two sprinkler heads in the x-ray room in the orthopedics area (identified as rental space) on the first floor are obstructed due to the suspended ceiling having been installed beneath the sprinkler heads.

Interview during tour on 8/15/12 and 8/16/12 with Staff B and Staff C at the time of discovery confirmed the findings.

18.3.2.4, NFPA 101, LIFE SAFETY CODE
Medical Gas: Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

4-5.1.1.1, NFPA 99, HEALTH CARE FACILITIES
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Based on observation and interview the facility failed to ensure that all medical gas cylinders are properly secured.

Findings include:

Observation during tour on 8/15/12 at approximately 1:00 p.m. with Staff B (Maintenance Supervisor) and Staff C (Quality Assessment) revealed that the medical gas supply room has at least 8 oxygen cylinders, 2 nitrogen cylinders, 2 carbon dioxide cylinders, 2 nitrous oxide cylinders, and 3 compressed air cylinders which are not independently secured.

Interview during tour on 8/15/12 with Staff B and Staff C at the time of discovery confirmed the findings.

18.3.7.3, NFPA 101, LIFE SAFETY CODE
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 hour.

8.3.6.1, NFPA 101, LIFE SAFETY CODE
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on record review, interview, and observation the facility failed to ensure that all smoke barrier penetrations are properly protected.

Findings include:

Record review of facility floor plans during tour on 8/15/12 revealed the locations of smoke barriers in the facility.

Interview during tour on 8/15/12 with Staff B (Maintenance Supervisor) and Staff C(Quality Assessment) confirmed the locations of smoke barriers.

Observation during tour between 8/15/12 at approximately 11:45 a.m. and 8/16/12 at approximately 10:45 a.m. with Staff B and Staff C revealed the following:

1. Smoke barrier at the emergency department corridor near room U710 has a partially protected penetration.

2. Smoke barrier at the second floor at the separation between the corridor and triage room has at least one penetration partially sealed.

3. Smoke barrier at the second floor in the area of door #2300B has at least one partially sealed large diameter opening and at least two insulated metal pipes with firestop collars improperly installed due to improper sizing as the collars are not tight fitting.

Record review during tour on 8/16/12 with Staff B and Staff C at the time of discovery revealed that the manufacturers specifications for the firestop collars are not for use with metal pipes and that the fastening clips are not installed according to manufacturers specifications.

Interview during tour on 8/15/12 with Staff B and Staff C confirmed the findings at the time of discovery.

18.5.1.1, NFPA 101, LIFE SAFETY CODE
Utilities shall comply with the provisions of Section 9.1.

9.1.2, NFPA 101, LIFE SAFETY CODE
Electric: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

110-26, NFPA 70, NATIONAL ELECTRICAL CODE
Spaces About Electrical Equipment: Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.

(a) Working Space: 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.

(1) Depth of Working Space: The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a).
Table 110-26(a). Working Spaces
Nominal Voltage to Ground: 0-150
Minimum Clear Distance (ft) (Condition 1): 3
Condition 1 - Exposed live parts on one side and no live or grounded parts on the other side of the working space, or exposed live parts on both sides effectively guarded by suitable wood or other insulating materials. Insulated wire or insulated busbars operating at not over 300 volts to ground shall not be considered live parts.

(2) Width of Working Space: The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

(3) Height of Working Space: The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26(e). Within the height requirements of this section, other equipment associated with the electrical installation located above or below the electrical equipment shall be permitted to extend not more than 6 in. (153 mm) beyond the front of the electrical equipment.

(b) Clear Spaces: Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

(e) Headroom: The minimum headroom of working spaces about service equipment, switchboards, panelboards, or motor control centers shall be 6-1/2 ft (1.98 m). Where the electrical equipment exceeds 6-1/2 ft (1.98 m) in height, the minimum headroom shall not be less than the height of the equipment.

370-28, NFPA 70, NATIONAL ELECTRICAL CODE
Pull and Junction Boxes: Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d).
(c) Covers: All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use.

Based on observation the facility failed to ensure that electrical installations are properly maintained.

Findings include:

Observation during tour on 8/15/12 between 11:00 a.m. and 2:00 p.m. with Staff B (Maintenance Supervisor) and Staff C (Quality Assessment) revealed the following:

1. Emergency department, room U625a, decontamination room: Items stored in front of and within 3 feet of the electrical distribution panels.

2. Operating Room back hallway: At least two electrical pull/junction boxes without covers installed above the suspended ceiling near the area of electrical distribution panels LP1A and CB1C.

Interview during tour on 8/15/12 with Staff B and Staff C confirmed the findings at the time of discovery.

8.2.2.2, NFPA 101, LIFE SAFETY CODE
Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.

8.2.3.2.4.2, NFPA 101, LIFE SAFETY CODE
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on record review, interview, and observation the facility failed to ensure that fire barriers are properly protected and fire doors have self-closing devices installed.

Findings include:

Record review of facility floor plans during tour on 8/15/12 revealed the locations of fire barriers in the facility.

Interview during tour on 8/15/12 with Staff B (Maintenance Supervisor) and Staff C (Quality Assessment) confirmed the locations of two hour fire barriers.

Observation during tour on 8/15/12 between 1:00 p.m. and 2:00 p.m. with Staff B and Staff C revealed the following:

1. The fire barrier separating med surge from the area of the operating room and radiology has at least one pvc pipe greater than 2 inches in diameter that is not properly protected with a firestop collar.

2. The corridor leading to med surge near door 1900 has at least one unprotected penetration.

3. The fire barrier at the special care unit supply area has at least one unprotected penetration.

Interview during tour on 8/15/12 with Staff B and Staff C confirmed the findings.

18.3.1.1, NFPA 101, LIFE SAFETY CODE
Any vertical opening shall be enclosed or protected in accordance with 8.2.5.

8.2.5.2, NFPA 101, LIFE SAFETY CODE
Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

8.2.3.2.1, NFPA 101, LIFE SAFETY CODEDoor assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

1-6.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled fire doors shall be used.

2-3.1.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled door frames shall be used.

Based on observation and interview the facility failed to ensure that doors in enclosed stairwells have appropriately rated door leafs and frames.

Findings include:

Observation during tour on 8/16/12 at approximately 10:00 a.m. with Staff B (Maintenance Supervisor) and Staff C (Quality Assessment) revealed that the enclosed stairwell door assembly (door #1502) has a door frame with a label demonstrating that it has a 20 minute fire protection rating and the door leaf is not labeled.

Interview during tour on 8/16/12 with Staff B and Staff C at the time of discovery confirmed the findings.

18.3.7.6, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 18.2.2.2.6.

8.3.4.1, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

A.8.3.4.1, NFPA 101, LIFE SAFETY CODE
The clearance for proper operation of smoke doors is defined as 1/8 in. (0.3 cm). For additional information on the installation of smoke-control door assemblies, see NFPA 105, Recommended Practice for the Installation of Smoke-Control Door Assemblies.

8.3.4.3, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

18.2.2.2.6, NFPA 101, LIFE SAFETY CODE
Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure (except boiler rooms, heater rooms, and mechanical equipment rooms) 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 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.

A.18.2.2.2.6, NFPA 101, LIFE SAFETY CODE
It is desirable to keep doors in exit passageways, stair enclosures, horizontal exits, smoke barriers, and required enclosures around hazardous areas closed at all times to impede the travel of smoke and fire gases. Functionally, however, this involves decreased efficiency and limits patient observation by the staff of an institution. To accommodate such needs, it is practical to presume that such doors will be kept open, even to the extent of employing wood chocks and other makeshift devices. Doors in exit passageways, horizontal exits, and smoke barriers should, therefore, be equipped with automatic hold-open devices activated by the methods described, regardless of whether the original installation of the doors was predicated on a policy of keeping them closed.

7.2.1.8.1, NFPA 101, LIFE SAFETY CODE
A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

7.2.1.8.2, NFPA 101, LIFE SAFETY CODE
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.

Based on record review, interview, and observation the facility failed to ensure that all smoke barrier doors have self-closing devices installed.

Findings include:

Record review of facility floor plans during tour on 8/15/12 revealed the locations of smoke barriers and smoke barrier doors in the facility.

Interview during tour on 8/15/12 with Staff B (Maintenance Supervisor) and Staff C (Quality Assessment) confirmed the locations of smoke barriers and smoke barrier doors.

Observation during tour on 8/15/12 between 12:30 p.m. and 3:00 p.m. revealed the following smoke barrier doors do not have self-closing devices installed:

1. Smoke barrier door #U325.

2. Smoke barrier door at registration.

3. Smoke barrier door #1303B at rehabilitation waiting area.

Interview during tour on 8/15/12 with Staff B and Staff C confirmed the findings at the time of discovery.

18.3.2.1, NFPA 101, LIFE SAFETY CODE
Hazardous Areas: Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated.

8.4.1.3, NFPA 101, LIFE SAFETY CODE
Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.

7.2.1.8.1, NFPA 101, LIFE SAFETY CODE
A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on observation and interview the facility failed to ensure that all hazardous areas have self-closing doors installed.

Findings include:

Observation during tour on 8/15/12 at approximately 1:40 p.m. with Staff B (Maintenance Supervisor) and Staff C (Quality Assessment) revealed that the door to the dirty utility room, door #U312, in the special care unit does not have a self-closing device installed.

Interview during tour on 8/15/12 with Staff B and Staff C at the time of discovery confirmed the findings.

18.3.5.1, NFPA 101, LIFE SAFETY CODE
Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

9.7.1.1, NFPA 101, LIFE SAFETY CODE
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.

9.7.5, NFPA 101, LIFE SAFETY CODE
Maintenance and Testing: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

5-1.1, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

5-6.5.1.2 Sprinklers shall be arranged to comply with... Table 5-6.5.1.2
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP):

Distance from Sprinklers to Side of Obstruction: Less than 1 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 0

Distance from Sprinklers to Side of Obstruction: 1 ft to less than 1 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 2-1/2

Distance from Sprinklers to Side of Obstruction: 1 ft 6 in. to less than 2 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 3-1/2

Distance from Sprinklers to Side of Obstruction: 2 ft to less than 2 ft 6 in.

Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 5-1/2

Distance from Sprinklers to Side of Obstruction: 2 ft 6 in. to less than 3 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 7-1/2

Distance from Sprinklers to Side of Obstruction: 3 ft to less than 3 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 9-1/2

Distance from Sprinklers to Side of Obstruction: 3 ft 6 in. to less than 4 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 12

Distance from Sprinklers to Side of Obstruction: 4 ft to less than 4 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 14

Distance from Sprinklers to Side of Obstruction: 4 ft 6 in. to less than 5 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 16-1/2

Distance from Sprinklers to Side of Obstruction: 5 ft and greater
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 18

2-2.1.1, NFPA 25, WATER-BASED FIRE PROTECTION SYSTEMS
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.

Based on observation and interview the facility failed to ensure that the spray patterns of sprinkler heads are not obstructed.

Findings include:

Observation during tour between 8/15/12 at approximately 11:15 a.m. and 8/16/12 at approximately 10:00 a.m. with Staff B (Maintenance Supervisor) and Staff C (Quality Assessment) revealed the following:

1. One sprinkler head with an obstructed spray pattern from a light fixture in the Emergency Department corridor. The deflector of the sprinkler head is approximately 5-1/4 inches from the ceiling, the thickness of the light fixture is approximately 6-3/4 inches from the ceiling, with the distance from the light fixture to the sprinkler head is approximately 10 inches apart.

2. At least two sprinkler heads in the x-ray room in the orthopedics area (identified as rental space) on the first floor are obstructed due to the suspended ceiling having been installed beneath the sprinkler heads.

Interview during tour on 8/15/12 and 8/16/12 with Staff B and Staff C at the time of discovery confirmed the findings.

18.3.2.4, NFPA 101, LIFE SAFETY CODE
Medical Gas: Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

4-5.1.1.1, NFPA 99, HEALTH CARE FACILITIES
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Based on observation and interview the facility failed to ensure that all medical gas cylinders are properly secured.

Findings include:

Observation during tour on 8/15/12 at approximately 1:00 p.m. with Staff B (Maintenance Supervisor) and Staff C (Quality Assessment) revealed that the medical gas supply room has at least 8 oxygen cylinders, 2 nitrogen cylinders, 2 carbon dioxide cylinders, 2 nitrous oxide cylinders, and 3 compressed air cylinders which are not independently secured.

Interview during tour on 8/15/12 with Staff B and Staff C at the time of discovery confirmed the findings.

18.3.7.3, NFPA 101, LIFE SAFETY CODE
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 hour.

8.3.6.1, NFPA 101, LIFE SAFETY CODE
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on record review, interview, and observation the facility failed to ensure that all smoke barrier penetrations are properly protected.

Findings include:

Record review of facility floor plans during tour on 8/15/12 revealed the locations of smoke barriers in the facility.

Interview during tour on 8/15/12 with Staff B (Maintenance Supervisor) and Staff C(Quality Assessment) confirmed the locations of smoke barriers.

Observation during tour between 8/15/12 at approximately 11:45 a.m. and 8/16/12 at approximately 10:45 a.m. with Staff B and Staff C revealed the following:

1. Smoke barrier at the emergency department corridor near room U710 has a partially protected penetration.

2. Smoke barrier at the second floor at the separation between the corridor and triage room has at least one penetration partially sealed.

3. Smoke barrier at the second floor in the area of door #2300B has at least one partially sealed large diameter opening and at least two insulated metal pipes with firestop collars improperly installed due to improper sizing as the collars are not tight fitting.

Record review during tour on 8/16/12 with Staff B and Staff C at the time of discovery revealed that the manufacturers specifications for the firestop collars are not for use with metal pipes and that the fastening clips are not installed according to manufacturers specifications.

Interview during tour on 8/15/12 with Staff B and Staff C confirmed the findings at the time of discovery.

18.5.1.1, NFPA 101, LIFE SAFETY CODE
Utilities shall comply with the provisions of Section 9.1.

9.1.2, NFPA 101, LIFE SAFETY CODE
Electric: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

110-26, NFPA 70, NATIONAL ELECTRICAL CODE
Spaces About Electrical Equipment: Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.

(a) Working Space: 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.

(1) Depth of Working Space: The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a).
Table 110-26(a). Working Spaces
Nominal Voltage to Ground: 0-150
Minimum Clear Distance (ft) (Condition 1): 3
Condition 1 - Exposed live parts on one side and no live or grounded parts on the other side of the working space, or exposed live parts on both sides effectively guarded by suitable wood or other insulating materials. Insulated wire or insulated busbars operating at not over 300 volts to ground shall not be considered live parts.

(2) Width of Working Space: The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

(3) Height of Working Space: The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26(e). Within the height requirements of this section, other equipment associated with the electrical installation located above or below the electrical equipment shall be permitted to extend not more than 6 in. (153 mm) beyond the front of the electrical equipment.

(b) Clear Spaces: Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

(e) Headroom: The minimum headroom of working spaces about service equipment, switchboards, panelboards, or motor control centers shall be 6-1/2 ft (1.98 m). Where the electrical equipment exceeds 6-1/2 ft (1.98 m) in height, the minimum headroom shall not be less than the height of the equipment.

370-28, NFPA 70, NATIONAL ELECTRICAL CODE
Pull and Junction Boxes: Boxes and conduit bodies used as pull or junction boxes shall comply with (a) through (d).
(c) Covers: All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use.

Based on observation the facility failed to ensure that electrical installations are properly maintained.

Findings include:

Observation during tour on 8/15/12 between 11:00 a.m. and 2:00 p.m. with Staff B (Maintenance Supervisor) and Staff C (Quality Assessment) revealed the following:

1. Emergency department, room U625a, decontamination room: Items stored in front of and within 3 feet of the electrical distribution panels.

2. Operating Room back hallway: At least two electrical pull/junction boxes without covers installed above the suspended ceiling near the area of electrical distribution panels LP1A and CB1C.

Interview during tour on 8/15/12 with Staff B and Staff C confirmed the findings at the time of discovery.