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Based on observations, staff interview, and/or documentation on July 10, 2018 at 11:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The ceiling assembly in rooms 140, 139, 115 and 116 is not maintained in good condition. There are ceiling tiles damaged and missing and have not been replaced.
Reference NFPA 101: Table 19.1.6.1, unless otherwise permitted by NFPA 101: 19.1.6.2 through 19.1.6.7; 19.1.6.4, 19.1.6.5 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, or other features 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.
2012 NFPA 101: 19.7.6; 4.6.12.1

This deficiency affected three smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on July 10, 2018 at 11:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The exit door to the central storage room (combustible storage) greater than 50 square feet located on the rear loading dock area was not equipped with a self-closing device as specified by NFPA 101: 19.3.2.1.3 - The doors shall be self-closing or automatic-closing.
2. The human resources office was converted to a clean linen storage room greater than 100 square feet. The room is not one hour fire rated construction but does have sprinkler protection except in the space between the lay-in ceiling tile and roof decking where the space is insulated with paper back insulation. The space between the lay-in ceiling will be need to have the paper back insulation removed or have sprinkler coverage provided as specified by NFPA 101, 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1.
3. The medical records (combustible) storage room is greater than 100 square feet and is equipped with sprinkler coverage except in the south east corner of the room where additional sprinkler cover is needed as specified by NFPA 101, 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1.
4. The opening in the wall between the medical records room and office area is not equipped with a fire rated door and frame as specified by NFPA 101: 19.3.2.1. Where the sprinkler option of NFPA 101: 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4. The door in the opening shall be as specified by 101: 8.4.3.1 - Doors in smoke partitions shall comply with 8.4.3.2 through 8.4.3.5.

NFPA Standard: NFPA 101, 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1.
19.3.2.1.1 An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9.
19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.
19.3.2.1.3 The doors shall be self-closing or automatic-closing.
19.3.2.1.4 Doors in rated enclosures shall be permitted to have non rated, factory- or field-applied protective plates extending not more than 48 in. (1220 mm) above the bottom of the door.
19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal
(242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard

This deficiency affected two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on July 10, 2018 at 11:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The supervisory signal for the electronically supervised tamper alarm on the sprinkler control valve at the Fire Alarm Control Panel (FACP) could be silenced permanently when the valve was in the closed position in the sprinkler riser room. Supervisory signals shall not be silenced permanently except by reopening/restoration of the valve to the normal operating position.

Reference 2012 NFPA 101 Section 19.3.5.1, 9.7.2.1 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 and Signaling Code, AND a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed at a location within the protected building that is constantly attended by qualified personnel.


This deficiency affected the entire facility.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on July 10, 2018 at 11:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The sprinkler gauges for the sprinkler system were dated 2002 and documentation was not available to indicate that the gauges were replaced or re-calibrated.

NFPA Standard: NFPA 101, 9.7.5 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.
NFPA Standard: NFPA 25, 5.1.1.1 This chapter shall provide the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.
5.1.1.2 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
Table 5.1.1.2 Summary of Sprinkler System Inspection, Testing, and Maintenance
Inspection
Gauges (dry, preaction, and deluge systems)
Weekly/monthly 5.2.4.2, 5.2.4.3, 5.2.4.4
Control valves Table 13.1
Waterflow alarm devices Quarterly 5.2.5
Valve supervisory alarm devices Quarterly 5.2.5
Supervisory signal devices (except valve supervisory switches) Quarterly 5.2.5
Gauges (wet pipe systems) Monthly 5.2.4.1
Hydraulic nameplate Quarterly 5.2.6
Buildings Annually (prior to freezing weather) 4.1.1.1
Hanger/seismic bracing Annually 5.2.3
Pipe and fittings Annually 5.2.2
Sprinklers Annually 5.2.1
Spare sprinklers Annually 5.2.1.4
Information sign Annually 5.2.6.1
Fire department connections Table 13.1
Valves (all types) Table 13.1
Obstruction, internal inspection of piping 5 years 14.2
Test
Waterflow alarm devices
Mechanical devices Quarterly 5.3.3.1
Vane and pressure switch type devices Semiannually 5.3.3.2
Valves supervisory alarm devices Table 13.1
Supervisory signal devices (except valve supervisory switches)
Table 13.1
Main drain Table 13.1
Antifreeze solution Annually 5.3.4
Gauges 5 years 5.3.2
Sprinklers - extra-high temperature 5 years 5.3.1.1.1.4
Sprinklers - fast-response At 20 years and every 10 years thereafter 5.3.1.1.1.3
Sprinklers At 50 years and every 10 years thereafter 5.3.1.1.1
Sprinklers At 75 years and every 5 years thereafter 5.3.1.1.1.5
Sprinklers - dry At 10 years and every 10 years thereafter 5.3.1.1.1.6
Maintenance
Valves (all types) Table 13.1
Low-point drains (dry pipe system) 13.4.4.3.2
Sprinklers and automatic spray nozzles protecting commercial cooking equipment and ventilation systems
Annually 5.4.1.9
14.2 Internal Inspection of Piping.
14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material.
14.2.1.1 Alternative nondestructive examination methods shall be permitted.

This deficiency affected the sprinkler system.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on July 10, 2018 at 11:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The corridor doors to the soiled utility room and clean utility room in the emergency room were equipped with roller latches and and not self latching hardware.
2. The Corridor fire/ smoke barrier doors at health information and at registration coordinators office was not self-closing .
NFPA 101: 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485

This deficiency affected one smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on July 10, 2018 at 11:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The smoke barrier walls between rooms 116 and 115, have holes and penetrations that were not sealed.
2. The smoke barrier in the corridor above the cross corridor door next to the x-ray department has unsealed penetrations under the HVAC duct penetrating the wall that were not properly sealed.
3. The smoke damper located in the smoke barrier wall between room 116 and 115 did not close when tested.
4. The two smoke dampers located in the equipment room smoke wall adjacent to room 128 did not operate when tested. Devices and equipment, systems will need to be maintained in good condition.
2012 NFPA 101: 19.3.7.3; 8.5.5, 4.5.8

This deficiency affected six smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on July 10, 2018 at 11:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The remote generator annunciator located at the nurse station did not provide a signal for loss of (Emergency Power Supply) EPS supplying load or a battery charger AC failure when checked.
2012 NFPA 99: 6.4.1.1.16.2 (Table item O),


This deficiency affected emergency power system.
Failure to comply with minimum standards as referenced increases the risk of death due to loss of power.

Based on observations, staff interview, and/or documentation on July 10, 2018 at 11:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The oxygen and nitrous oxide storage room is a non sprinkler space and there are combustibles stored within 20 feet of the compresses gas and has a nonflammable gases volume greater than than 85 m3 (3000 ft3).
2. The Type E oxygen cylinders in the oxygen storage room are stored in a combustible wood storage rack.
3. Full and empty cylinders were stored in the same rack and not separated full from empty.

NFPA 99: 5.1.3.3.2 Design and Construction
2012 NFPA 19.3.2.4, 99 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders.

This deficiency affected one smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.