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NFPA 101 (2012 edition) LIFE SAFETY CODE
19.2.2.2.1 Doors complying with 7.2.1 shall be permitted

7.2.1.15 Inspection of Door Openings
7.2.1.15.1 Where required by Chapters 11 through 43, the following door assemblies shall be inspected and tested not less than annually in accordance with 7.2.1.15.2 through 7.2.1.15.8:
(1) Door leaves equipped with panic hardware or fire exit hardware in accordance with 7.2.1.7.
(2) Door assemblies in exit enclosures.
(3) Electrically controlled egress doors.
(4) Door assemblies with special locking arrangements subject to 7.2.1.6.

7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80 STANDARD for FIRE DOORS and other OPENING PROTECTIVE'S.

NFPA 80 STANDARD for FIRE DOORS and other OPENING PROTECTIVE'S
5.2 Inspections
5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

Based on record review and interview the facility failed to inspect and test fire door assemblies.

Findings include:

Record review during tour on 07/12/17 between 7:30 a.m. and 3:00 p.m. with Staff A (Facilities Manager) revealed that an annual Fire Door Assembly inspection and documentation was not provided for review.

Interview with Staff A confirmed the findings.

Based on observations and interview the facility failed to ensure that 1 door, in a fire rated wall, was equipped with an automatic door closing device.

Findings include:

Observations during tour on 07/13/17 between 11:45 a.m. and 12:15 p.m. with Staff A (Facilities Manager) revealed 1 storage room entry door, in a 1 hour fire rated barrier, labeled "Rooftop Access" and located outside of the Pharmacy, failed to be equipped with an automatic door closing device.

Interview with Staff A confirmed the findings and location.

NFPA 101 LIFE SAFETY CODE (2012 edition)
7.2.9.4 Emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110 STANDARD for EMERGENCY and STANDBY POWER SYSTEMS (2010 edition).
7.9.3.1.1 Testing of the emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds.
(2) The test interval shall be permitted to be extended beyond 30 days with the approval of the AHJ (Authority Having Jurisdiction).
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3).

NFPA 110 STANDARD for EMERGENCY and STANDBY POWER SYSTEMS (2010 edition)
7.3 Lighting
7.3.1 The level 1 or level 2 EPS (Emergency Power Supply) equipment locations shall be provided with battery powered emergency lighting.
This requirement shall not apply to units located outdoors in enclosures that do not include walk in access.

Based on observations, record review and interview the facility failed to ensure that the annual 1 1/2 hour battery powered, emergency lighting functional test was conducted and that battery powered emergency lighting was located at 2 separate EPS equipment locations.

Findings include:

Observations during tour on 07/12/17 and 07/13/17 with Staff A (Facilities Director) revealed that no documentation of the annual emergency lighting tests could be provided. Observations also revealed that 2 separate locations contain ATS (automatic transfer switchgear) equipment for the emergency power systems and failed to be equipped with battery powered emergency lighting. These locations are as follows:
1. The "Emergency Power Room" contains 1 ATS electrical panel and failed to be equipped with emergency lighting.
2. The "Main Electrical Room", located next to the Boiler room, contains 1 ATS electrical panel and failed to be equipped with emergency lighting.

Interview with Staff A confirmed the findings and locations.

Based on observations and interview the facility failed to ensure that automatic door closing devices are installed or maintained on 5 separate doors to potentially hazardous areas.

Findings include:

Observations and interview during tour on 07/13/17 between 8:45 a.m. and 12:30 p.m. with Staff A (Facilities Manager) revealed that 5 rooms used for quantities of supply storage, and exceed 50 sq. ft. in size, failed to have doors equipped with automatic door closing device's.
These 5 doors and locations are as follows:
(1) The storage room door, next to room #116 (over 50 sq. ft.) failed to be equipped with a closing device.
(2) The storage room door, outside the "charting station" (over 50 sq.ft.) failed to be equipped with a closing device.
(3) The house keeping closet, next to the "case managers office" (over 50 sq. ft.) failed to be equipped with a closing device.
(4) The soiled utility closet # 1010 had the closer arms disconnected.
(5) The Biohazard storage room, on the lower level, has had the door closing device disabled and a portion of the interior wall was removed to accommodate for a steel beam installation. The wall has an unprotected opening of approximately 14 sq. ft. into the maintenance workshop.

Interview with Staff A confirmed the findings, locations, and conditions of the Biohazard wall.

NFPA 96 (2011 edition) Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations

11.2.1 Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person (s) acceptable to the authority having jurisdiction at least every 6 months.

11.2.4 Fusible links of the metal alloy type shall be replaced at least semiannually.

Based on record review and interview the facility failed to ensure that the Kitchen Hood suppression system was serviced on a semi-annual basis.

Findings include:

Record review during tour on 07/12/17 between 11:30 a.m. and 12:00 p.m. with Staff A (Facilities Manager) revealed documentation that kitchen exhaust hood vendor had completed the last service on 06/01/17, the previous service documentation was completed on 07/22/16. Staff A failed to produce any additional documentation of service dates.

Interview with Staff A confirmed the findings.

NFPA 25 (2011 edition) Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems
5.2.1.1.1* Sprinklers shall not show signs of leakage, shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation ( e.g., upright, pendant, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:

(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5) Loading
(6) Painting unless painted by the manufacturer

A 5.2.1.1.1 (5) In lieu of replacing sprinklers that are loaded with a coating of dust, it is permitted to clean sprinklers with compressed air or by a vacuum provided that the equipment does not touch the sprinkler.

Based on observations and interview the facility failed to ensure that several sprinkler heads were not "loaded" with dust/lint/debris.

Findings include:

Observations during tour on 07/13/17 between 7:30 a.m. and 2:30 p.m. with Staff A (Facilities Manager) revealed sprinklers heads covered with dust/lint in several departments of the facility. The majority of the locations are next to an HVAC vent register.
Some of these areas are as follows:
The main lobby has at least 3 heads covered with lint.
The Lab has at least 2 heads covered with lint.
The kitchen and dishwashing area have at least 4 heads covered with lint.
The emergency department has at least 2 heads covered with lint.
The registration area has at least 2 heads covered with lint.

Interview with Staff A confirmed the findings.

Based on observations and interview the facility failed to ensure that the 2 hour fire barrier separation is maintained to prevent the passage of smoke/fire.

Findings include:

Observations during tour on 07/13/17 between 1:30 p.m. and 3:00 p.m. with Staff A (Facilities Manager) revealed that the 2 hour fire barrier wall, above the suspended ceiling, in the Lab Receiving Suite had at least 12 unprotected penetrations through both sides of the fire wall. Some of these penetrations consist of:
1. Several flexible metal electrical conduits.
2. Several 2 1/2" copper water lines.
3. Several miscellaneous electrical/computer wires.
4. 1 sprinkler pipe.

The 2 hour fire barrier separation between the registration area and the doctors office's, above the suspended ceiling, has at least 1 unprotected penetration through the fire barrier.
1. 3/4" Metal electrical conduit.

Interview with Staff A confirmed the locations and findings.

Based on record review and interview the facility failed to ensure that the emergency generator vendor conducted a 4 hour load test every 36 months.

Findings include:

Record review during tour on 07/12/17 between 11:00 a.m and 11:30 a.m. with Staff A (Facilities Manager) revealed documentation of a 4 hour generator load bank test conducted in 2013. The facility failed to provide documentation of a 4 hour load bank test for 2016.

Interview with Staff A confirmed the findings.

Based on observations and interview the facility failed to ensure that 3 non-hospital grade plug strips and 1 extension cord were not in permanent use.

Findings include:

Observations during tour on 07/13/17 between 7:30 a.m. and 1:30 p.m. with Staff A (Facilities Manager) revealed 4 locations with non-hospital grade plug strips or extension cords for permanent use.
These locations are as follows:
1. The doctors charting station had 1 plug strip under the desk.
2. A plug strip was in use under the desk in mammography suite.
3. A plug strip was in use under the desk in occupational therapy suite.
4. An extension cord was in use in the Lab, powering the incubator.

Interview with Staff A confirmed the findings and locations.