HospitalInspections.org

Based on observation and documentation review, it was determined that the facility failed to meet the building services requirements in accordance with NFPA 101, 80, 90A, and 105. This was evidenced by:

Review of facility-furnished documentation, the facility has 13 non-functioning fire/smoke dampers in the facility.

This deficiency has the potential to affect occupants, who might include patients, staff, and visitors within all smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.

NFPA 101 4.6.12.1
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

NFPA 80 19.4.5
The operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts.