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Approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or floors required to have a fire resistance rating of 2 hours or more.

The facility failed to maintain the two-hour fire resistive rating of the floor/ceiling assembly throughout the building.

Observation determined:

1) The fourth floor East Mechanical Room had a return air duct penetrating through the ceiling to the fifth floor Women Health Room. The duct was not equipped with a fire damper.

2) The second floor Old OB Office had a return air duct penetrating through the ceiling to the third floor North Mechanical Room. The duct was not equipped with a fire damper.

The deficiency affected four (4) of five (5) floors in the facility.

Ref: 2000 NFPA 101 Section 19.1.6.2, 8.2.1; 1999 NFPA 90A 3-3.1.

The facility failed to ensure the corridor doors latched into their frames and resisted the passage of smoke.

Observation determined:

1) The door to the Linen Room across from Patient Room 201 on the second floor did not have latching hardware.

2) The Nutrition Room on the second floor had no door separating the room from the corridor. The area also had no smoke detector.

The deficiency affected two (2) of numerous corridor doors in the facility.

1) The facility failed to ensure exits were arranged to provide a continuous path of escape.

Observation determined the access to the east stair enclosure on the fourth and fifth floor was through intervening spaces. The fourth floor must exit through the Surgical Suite and the fifth floor must exit through the PT/OT Suite to reach the east stair enclosure.

2) The facility failed to ensure stairways were enclosed with construction having a fire resistance rating of at least two hours.

Observation determined:

a) The fifth floor east stair enclosure wall between the PT/OT suite and the stairway terminated at the ceiling.

b) The latching hardware on the east stair enclosure doors on the second, third, fourth and fifth floors was not fire rated hardware.

The deficiency affected one (1) of five (5) stair enclosures in the facility.

The facility failed to test the fire alarm system as required.

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required by NFPA 72, National Fire Alarm Code. Load voltage tests were conducted annually with the last test performed on 12/18/2013.

The deficiency affected one (1) of two (2) required load voltage tests of the batteries in the last year. The fire alarm system serves the entire facility.

Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 table 7-3.2 item 6.d.3.

Automatic fire sprinkler systems must be installed in accordance with NFPA 13.

1) The facility failed to install the automatic sprinkler system in accordance with NFPA 13 to provide adequate coverage for all portions of the building.

Observation determined:

a) The storage area under the Penthouse stairs had no sprinkler coverage.

b) The first floor South Exit Vestibule had no sprinkler coverage.

c) The south riser sprinkler valve located in South Mechanical Room in the basement was not electronically monitored.

d) The Phone Equipment Room on the second floor had two (2) 12" x 24" openings in the suspended ceiling that could delay the activation of the sprinkler system.


2) Ordinary-temperature-rated sprinklers shall be used throughout buildings. NFPA 13, Section 5-3.1.5

The facility failed to provide ordinary-temperature-rated sprinklers throughout the facility.

Observation determined an intermediate-temperature-rated sprinkler was located in the fourth floor Women Bathroom.


The deficiency affected the entire building.

All Level 1 and Level 2 installations of an emergency generator 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.

For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. NFPA 110, Standard for Emergency and Standby Power Systems.

The facility failed to ensure the emergency generator was in compliance with NFPA 110.

Observation determined there was no remote stop switch for the generator located outside of the generator room.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.

Ref: 2000 NFPA 101 Section 19.2.9.1, 7.9.2.3, 1999 NFPA 110 Section 3-5.5.6

Flexible cords and cables must not be used as a substitute for fixed wiring of a structure. NFPA 70, National Electrical Code, 400-8

The facility failed to ensure electrical wiring and electrical equipment met NFPA 70 requirements.

Observation determined:

1) There was a power strip plugged into a multiplug adapter in the X-ray Manager's Office.

2) There was a C-PAP machine plugged into a power strip in the Sleep Study Room.

The deficiency affected two (2) of numerous areas in the facility.

Approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or floors required to have a fire resistance rating of 2 hours or more.

The facility failed to maintain the two-hour fire resistive rating of the floor/ceiling assembly throughout the building.

Observation determined:

1) The fourth floor East Mechanical Room had a return air duct penetrating through the ceiling to the fifth floor Women Health Room. The duct was not equipped with a fire damper.

2) The second floor Old OB Office had a return air duct penetrating through the ceiling to the third floor North Mechanical Room. The duct was not equipped with a fire damper.

The deficiency affected four (4) of five (5) floors in the facility.

Ref: 2000 NFPA 101 Section 19.1.6.2, 8.2.1; 1999 NFPA 90A 3-3.1.

The facility failed to ensure the corridor doors latched into their frames and resisted the passage of smoke.

Observation determined:

1) The door to the Linen Room across from Patient Room 201 on the second floor did not have latching hardware.

2) The Nutrition Room on the second floor had no door separating the room from the corridor. The area also had no smoke detector.

The deficiency affected two (2) of numerous corridor doors in the facility.

1) The facility failed to ensure exits were arranged to provide a continuous path of escape.

Observation determined the access to the east stair enclosure on the fourth and fifth floor was through intervening spaces. The fourth floor must exit through the Surgical Suite and the fifth floor must exit through the PT/OT Suite to reach the east stair enclosure.

2) The facility failed to ensure stairways were enclosed with construction having a fire resistance rating of at least two hours.

Observation determined:

a) The fifth floor east stair enclosure wall between the PT/OT suite and the stairway terminated at the ceiling.

b) The latching hardware on the east stair enclosure doors on the second, third, fourth and fifth floors was not fire rated hardware.

The deficiency affected one (1) of five (5) stair enclosures in the facility.

The facility failed to test the fire alarm system as required.

Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required by NFPA 72, National Fire Alarm Code. Load voltage tests were conducted annually with the last test performed on 12/18/2013.

The deficiency affected one (1) of two (2) required load voltage tests of the batteries in the last year. The fire alarm system serves the entire facility.

Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 table 7-3.2 item 6.d.3.

Automatic fire sprinkler systems must be installed in accordance with NFPA 13.

1) The facility failed to install the automatic sprinkler system in accordance with NFPA 13 to provide adequate coverage for all portions of the building.

Observation determined:

a) The storage area under the Penthouse stairs had no sprinkler coverage.

b) The first floor South Exit Vestibule had no sprinkler coverage.

c) The south riser sprinkler valve located in South Mechanical Room in the basement was not electronically monitored.

d) The Phone Equipment Room on the second floor had two (2) 12" x 24" openings in the suspended ceiling that could delay the activation of the sprinkler system.


2) Ordinary-temperature-rated sprinklers shall be used throughout buildings. NFPA 13, Section 5-3.1.5

The facility failed to provide ordinary-temperature-rated sprinklers throughout the facility.

Observation determined an intermediate-temperature-rated sprinkler was located in the fourth floor Women Bathroom.


The deficiency affected the entire building.

All Level 1 and Level 2 installations of an emergency generator 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.

For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. NFPA 110, Standard for Emergency and Standby Power Systems.

The facility failed to ensure the emergency generator was in compliance with NFPA 110.

Observation determined there was no remote stop switch for the generator located outside of the generator room.

The deficiency affected one (1) of one (1) emergency generator which provides all emergency power to the facility.

Ref: 2000 NFPA 101 Section 19.2.9.1, 7.9.2.3, 1999 NFPA 110 Section 3-5.5.6

Flexible cords and cables must not be used as a substitute for fixed wiring of a structure. NFPA 70, National Electrical Code, 400-8

The facility failed to ensure electrical wiring and electrical equipment met NFPA 70 requirements.

Observation determined:

1) There was a power strip plugged into a multiplug adapter in the X-ray Manager's Office.

2) There was a C-PAP machine plugged into a power strip in the Sleep Study Room.

The deficiency affected two (2) of numerous areas in the facility.