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Based on observation and staff interview, the facility failed to assure that fire doors in the 2 hour fire separation wall between the hospital and the business occupancy self close and latch properly. This deficient practice of allowing 1 ? hour fire rated doors in a 2 hour fire wall for occupancy separation to not latch when self-closing will allow smoke and fire products to pass from the health care occupancy to the other, affecting two of three smoke zones on the 2nd floor. The facility has a capacity of 9 with a census of 6 at the time of survey.

Findings Include:

During the tour on May 3rd, 2011 between 10:30 AM and 3:30 PM the following is observed:

The west leaf of the pair of 1 1/2 hour fire rated doors in the southeast 2 hour fire wall separating the hospital from the business occupancy would not latch when self closing.

Staff A was present and acknowledged that this door would not latch.

NFPA Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2 hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2

NFPA Standard: Occupied buildings shall meet the minimum construction requirements of the occupancy chapters and NFPA 220. Additions or connected structures of different construction types shall have the ratings and classification based on: separate buildings if a 2 hour or greater vertically aligned fire barrier wall in accordance with NFPA 221 exists between the buildings, or the least fire resistive type of construction of the connected portions. 2000 NFPA 101, 8.2.1

Based on observation and staff interview the facility is not ensuring that room doors latch properly. This deficient practice of not ensuring that room doors latch properly prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting one of three smoke zones. The facility has a capacity of 9 with a census of 6 at the time of survey.

Findings Include:

During the tour on May 3rd, 2011 between 10:30 AM and 3:30 PM the following is observed:

Doors to rooms 201, 206, 207 and the clean linen room are not latching properly.

Staff A was present at the time of the findings and acknowledged the findings.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop down or plunger type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting two of three smoke zones. The facility has a capacity of 9 with a census of 6 at the time of survey.

Findings Include:

During the tour on May 3rd, 2011 between 10:30 AM and 3:30 PM the following is observed:

1. Room A232, pre-op soiled utility room, is not equipped with a self closing device.
2. Laboratory door would not latch when self-closing.
3. The inpatient electrical room has penetrations in the wall above the door around conduit.

Staff A was present and acknowledged the finding. The room labeled soiled utility is being used for soiled linens at the time of the survey. The electrical room has evidence of past attempts to seal the penetrations from the room into the patient area, but not all the gaps and holes in the wall were sealed.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

NFPA Standard: Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42. 2000 NFPA 101, 8.4.1

Based on observation and staff interview the facility failed to provide continuous illumination of walking surfaces within an exit discharge to values of at least 1 ft candle (10 lux) measured at the floor. This deficient practice does not insure that exit paths will be illuminated continuously and will delay egress affecting there of three smoke zones. The facility has a capacity of 9 with a census of 6 at the time of survey.

Findings Include:

During the tour on May 3rd, 2011 between 10:30 AM and 3:30 PM the following is observed:

No normal illumination fixtures are provided at the exit discharge paths from the three exit stairways.

Staff A was present and acknowledged the findings. Staff A consulted with an electrician concerning the light fixtures at each of these exit discharge paths. The electrician indicated that the light fixtures were battery powered for emergency lighting only and do not provide lighting in the normal illumination mode.

NFPA Standard: Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
Exception: Automatic, motion sensor type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail safe operation, the illumination timers are set for a minimum 15 minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units. 2000 NFPA 101, Section 7.8.1.2

NFPA Standard: The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated to values of at least 1 ft candle (10 lux) measured at the floor.
Exception No. 1: In assembly occupancies, the illumination of the floors of exit access shall be at least 0.2 ft candle (2 lux) during periods of performances or projections involving directed light.
Exception No. 2:* This requirement shall not apply where operations or processes require low lighting levels. 2000 NFPA 101, Section 7.8.1.3

Based on records review and staff interview the facility failed to ensure that battery powered emergency lighting is tested for 90 minutes annually and documented. This deficient practice could result in the lights not operating for the minimum required time in the event of an emergency, affecting three of three smoke zones. The facility has a capacity of 9 with a census of 6 at the time of survey.

Findings Include:

During the tour on May 3rd, 2011 between 10:30 AM and 3:30 PM the following is observed:

There is no record indicating that the battery powered emergency lighting was tested for 90 minutes annually

Staff A was present and confirmed there was no record for a 90 minute annual test.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3 and 7.10.9

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drill. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency and affects three of three smoke zones. The facility has a capacity of 9 with a census of 6 at the time of survey.

Findings Include:

During the tour on May 3rd, 2011 between 10:30 AM and 3:30 PM the following is observed:

Findings Include:

Review of the facility's fire drill records for the previous 12 months revealed that fire drills were not conducted on the 1st shift for the 2nd and 3rd quarters of 2010 and the 2nd shift during the 1st quarter of 2011 and the 2nd and 3rd quarters of 2010.

Staff A was present during record review and acknowledged that fire drills have not been performed and documented as required.

NFPA Standard: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 19.7.1.2

Based on observation, interview and record review, the facility failed to provide annual inspection and testing of the fire alarm system as required by NFPA 72. The absence of complete, verifiable documented maintenance and repair history on the fire alarm system fails to ensure reliability of the alarm system in the event of an emergency, affecting three of three smoke zones. The facility has a capacity of 9 with a census of 6 at the time of survey.

Findings Include:

During the tour on May 3rd, 2011 between 10:30 AM and 3:30 PM the following is observed:

Record review of the facility's annual fire alarm system inspection and testing revealed that notification devices had not been tested within the last 12 months.

Staff A was present during record review and produced an inspection and testing document rendered by two separate fire alarm companies during 2010 and neither of the inspection and testing documents indicated that the notification device had been sounded. The December 29, 2010 report from Simplex/Grinnell indicated that the notification devices were not sounded per customers request and the August 15, 2010 inspection and testing document from Keller Fire and Safety did not list any notification devices on their report

NFPA Standard: 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. 2000 NFPA 101, 9.6.1.4

NFPA Standard: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7 2.2. 1999 NFPA 72, 7-2.2

NFPA Standard: A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) *Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15)Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place) 1999 NFPA 72, 7-5.2.2

Based on observation and staff interview the facility failed to maintain the sprinkler system in accordance with NFPA 13 and NFPA 25. This deficient practice may prevent the effective operation of the fire suppression system in the event of a fire, affecting three of three smoke zones. The facility has a capacity of 9 with a census of 6 at the time of survey.

Findings Include:

During the tour on May 3rd, 2011 between 10:30 AM and 3:30 PM the following is observed:

1. Room A235 labeled pre-op #4 - missing escutcheon ring.
2. Room A213 labeled office - loaded sprinkler head.
3. Room A217 Recovery rest room - corroded sprinkler head.
4. Room A232 pre-op soiled utility room - frangible bulb has been painted.
5. Nurse manager office - loaded sprinkler head.
6. Anesthesia work room - missing escutcheon ring
7. Food storage closet in the inpatient corridor - does not have 18 inches of clearance below the sprinkler head where installed directly above a shelf due to boxes of food.

Staff A was present at the time of the observation of these sprinkler deficiencies and agreed with the findings. Staff A called the sprinkler vendor and requested a service call to correct the deficiencies at the time of the survey.

NFPA Standard: 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. 2000 NFPA 101, 9.7.1.1

NFPA Standard: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets; restoring heat in areas subject to freezing temperatures where water filled piping is installed; and replacing worn or missing fire hose or nozzles. 1998 NFPA 25, 1 11.3

NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per NFPA 101, 9.7.5. Obstructions shall not prevent sprinkler discharge from reaching the protected area. Continuous or non-continuous obstructions that interrupt the water discharge in a horizontal plane more than 18 inches below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section. The requirements of this section shall also apply to obstructions 18 in. or less below the sprinkler for light and ordinary hazard occupancies per NFPA 13, 5-6.5.3. Water flow alarm devices including, but not limited to, mechanical water motor gongs, vane-type water flow devices, and pressure switches that provide audible or visual signals shall be tested quarterly per 1998 NFPA 25, 2-3.3

Based on observation and staff interview, the facility failed to assure that fire doors in the 2 hour fire separation wall between the hospital and the business occupancy self close and latch properly. This deficient practice of allowing 1 ? hour fire rated doors in a 2 hour fire wall for occupancy separation to not latch when self-closing will allow smoke and fire products to pass from the health care occupancy to the other, affecting two of three smoke zones on the 2nd floor. The facility has a capacity of 9 with a census of 6 at the time of survey.

Findings Include:

During the tour on May 3rd, 2011 between 10:30 AM and 3:30 PM the following is observed:

The west leaf of the pair of 1 1/2 hour fire rated doors in the southeast 2 hour fire wall separating the hospital from the business occupancy would not latch when self closing.

Staff A was present and acknowledged that this door would not latch.

NFPA Standard: Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2 hour fire resistance rating and constructed of materials as required for the addition. Communicating openings in the fire barriers shall be permitted only in corridors and protected by approved self closing fire doors. 2000 NFPA 101, 18/19.1.1.4.1 and 18/19.1.1.4.2

NFPA Standard: Occupied buildings shall meet the minimum construction requirements of the occupancy chapters and NFPA 220. Additions or connected structures of different construction types shall have the ratings and classification based on: separate buildings if a 2 hour or greater vertically aligned fire barrier wall in accordance with NFPA 221 exists between the buildings, or the least fire resistive type of construction of the connected portions. 2000 NFPA 101, 8.2.1

Based on observation and staff interview the facility is not ensuring that room doors latch properly. This deficient practice of not ensuring that room doors latch properly prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting one of three smoke zones. The facility has a capacity of 9 with a census of 6 at the time of survey.

Findings Include:

During the tour on May 3rd, 2011 between 10:30 AM and 3:30 PM the following is observed:

Doors to rooms 201, 206, 207 and the clean linen room are not latching properly.

Staff A was present at the time of the findings and acknowledged the findings.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop down or plunger type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting two of three smoke zones. The facility has a capacity of 9 with a census of 6 at the time of survey.

Findings Include:

During the tour on May 3rd, 2011 between 10:30 AM and 3:30 PM the following is observed:

1. Room A232, pre-op soiled utility room, is not equipped with a self closing device.
2. Laboratory door would not latch when self-closing.
3. The inpatient electrical room has penetrations in the wall above the door around conduit.

Staff A was present and acknowledged the finding. The room labeled soiled utility is being used for soiled linens at the time of the survey. The electrical room has evidence of past attempts to seal the penetrations from the room into the patient area, but not all the gaps and holes in the wall were sealed.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

NFPA Standard: Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42. 2000 NFPA 101, 8.4.1

Based on observation and staff interview the facility failed to provide continuous illumination of walking surfaces within an exit discharge to values of at least 1 ft candle (10 lux) measured at the floor. This deficient practice does not insure that exit paths will be illuminated continuously and will delay egress affecting there of three smoke zones. The facility has a capacity of 9 with a census of 6 at the time of survey.

Findings Include:

During the tour on May 3rd, 2011 between 10:30 AM and 3:30 PM the following is observed:

No normal illumination fixtures are provided at the exit discharge paths from the three exit stairways.

Staff A was present and acknowledged the findings. Staff A consulted with an electrician concerning the light fixtures at each of these exit discharge paths. The electrician indicated that the light fixtures were battery powered for emergency lighting only and do not provide lighting in the normal illumination mode.

NFPA Standard: Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
Exception: Automatic, motion sensor type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail safe operation, the illumination timers are set for a minimum 15 minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units. 2000 NFPA 101, Section 7.8.1.2

NFPA Standard: The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated to values of at least 1 ft candle (10 lux) measured at the floor.
Exception No. 1: In assembly occupancies, the illumination of the floors of exit access shall be at least 0.2 ft candle (2 lux) during periods of performances or projections involving directed light.
Exception No. 2:* This requirement shall not apply where operations or processes require low lighting levels. 2000 NFPA 101, Section 7.8.1.3

Based on records review and staff interview the facility failed to ensure that battery powered emergency lighting is tested for 90 minutes annually and documented. This deficient practice could result in the lights not operating for the minimum required time in the event of an emergency, affecting three of three smoke zones. The facility has a capacity of 9 with a census of 6 at the time of survey.

Findings Include:

During the tour on May 3rd, 2011 between 10:30 AM and 3:30 PM the following is observed:

There is no record indicating that the battery powered emergency lighting was tested for 90 minutes annually

Staff A was present and confirmed there was no record for a 90 minute annual test.

NFPA Standard: A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. 2000 NFPA 101, 7.9.3 and 7.10.9

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drill. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency and affects three of three smoke zones. The facility has a capacity of 9 with a census of 6 at the time of survey.

Findings Include:

During the tour on May 3rd, 2011 between 10:30 AM and 3:30 PM the following is observed:

Findings Include:

Review of the facility's fire drill records for the previous 12 months revealed that fire drills were not conducted on the 1st shift for the 2nd and 3rd quarters of 2010 and the 2nd shift during the 1st quarter of 2011 and the 2nd and 3rd quarters of 2010.

Staff A was present during record review and acknowledged that fire drills have not been performed and documented as required.

NFPA Standard: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 19.7.1.2

Based on observation, interview and record review, the facility failed to provide annual inspection and testing of the fire alarm system as required by NFPA 72. The absence of complete, verifiable documented maintenance and repair history on the fire alarm system fails to ensure reliability of the alarm system in the event of an emergency, affecting three of three smoke zones. The facility has a capacity of 9 with a census of 6 at the time of survey.

Findings Include:

During the tour on May 3rd, 2011 between 10:30 AM and 3:30 PM the following is observed:

Record review of the facility's annual fire alarm system inspection and testing revealed that notification devices had not been tested within the last 12 months.

Staff A was present during record review and produced an inspection and testing document rendered by two separate fire alarm companies during 2010 and neither of the inspection and testing documents indicated that the notification device had been sounded. The December 29, 2010 report from Simplex/Grinnell indicated that the notification devices were not sounded per customers request and the August 15, 2010 inspection and testing document from Keller Fire and Safety did not list any notification devices on their report

NFPA Standard: 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. 2000 NFPA 101, 9.6.1.4

NFPA Standard: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7 2.2. 1999 NFPA 72, 7-2.2

NFPA Standard: A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) *Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15)Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place) 1999 NFPA 72, 7-5.2.2

Based on observation and staff interview the facility failed to maintain the sprinkler system in accordance with NFPA 13 and NFPA 25. This deficient practice may prevent the effective operation of the fire suppression system in the event of a fire, affecting three of three smoke zones. The facility has a capacity of 9 with a census of 6 at the time of survey.

Findings Include:

During the tour on May 3rd, 2011 between 10:30 AM and 3:30 PM the following is observed:

1. Room A235 labeled pre-op #4 - missing escutcheon ring.
2. Room A213 labeled office - loaded sprinkler head.
3. Room A217 Recovery rest room - corroded sprinkler head.
4. Room A232 pre-op soiled utility room - frangible bulb has been painted.
5. Nurse manager office - loaded sprinkler head.
6. Anesthesia work room - missing escutcheon ring
7. Food storage closet in the inpatient corridor - does not have 18 inches of clearance below the sprinkler head where installed directly above a shelf due to boxes of food.

Staff A was present at the time of the observation of these sprinkler deficiencies and agreed with the findings. Staff A called the sprinkler vendor and requested a service call to correct the deficiencies at the time of the survey.

NFPA Standard: 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. 2000 NFPA 101, 9.7.1.1

NFPA Standard: Corrective maintenance includes, but is not limited to, replacing loaded, corroded, or painted sprinklers; replacing missing or loose pipe hangers; cleaning clogged fire pump impellers; replacing valve seats and gaskets; restoring heat in areas subject to freezing temperatures where water filled piping is installed; and replacing worn or missing fire hose or nozzles. 1998 NFPA 25, 1 11.3

NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per NFPA 101, 9.7.5. Obstructions shall not prevent sprinkler discharge from reaching the protected area. Continuous or non-continuous obstructions that interrupt the water discharge in a horizontal plane more than 18 inches below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section. The requirements of this section shall also apply to obstructions 18 in. or less below the sprinkler for light and ordinary hazard occupancies per NFPA 13, 5-6.5.3. Water flow alarm devices including, but not limited to, mechanical water motor gongs, vane-type water flow devices, and pressure switches that provide audible or visual signals shall be tested quarterly per 1998 NFPA 25, 2-3.3