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Based on observations, the facility failed to maintain the emergency lighting in accordance National Fire Protection Association (NFPA) Standard 101, 2000 edition. This deficient practice affects all occupants in the facility.

Findings include:

Observations and interview on 12/13/11, revealed the emergency light by the Supervisors Office in the Witwer Children's Center did not illuminate when tested. This was corrected by maintenance staff during the inspection. Safety Staff A verified this observation at the time of the survey process.

Based on observation and interview, this facility is not maintaining and providing the sprinkler system in accordance with the 1998 edition of National Fire Protection Association (NFPA) 25, and the 1999 edition of National Fire Protection Association (NFPA) 13. This can affect the operation of the heads by delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place all occupants at risk in the event of a fire.

Findings include:

1. Observation and interview on 12/14/11, revealed one standard sprinkler head in 5 Center Nurse's Work Station surrounded by quick response sprinkler heads. The area that was sprinklered with different types of heads were not separated from each other. This was verified with Maintenance Staff A.

2. Observation and interview on 12/14/11, revealed the Linen Storage room in the Basement had green Intermediate temperature sprinkler heads throughout the room. This room was formerly the location of the Laundry, and now is used for Linen Storage. Maintenance Staff A verified this finding.

3. Observation and interview on 12/14/11, revealed the walkway from the Atrium to the OB building did not have sprinkler coverage. Maintenance Staff A verified this finding.


NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. NFPA 13, 12.1

NFPA Standard: The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. NFPA 25, 1-4.4

NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. NFPA 25, 2-2.1.1


NFPA Standard: When existing light hazard systems are converted to use quick-response sprinklers, all sprinklers in the compartmented space shall be changed. 1999 NFPA 13, 5-3.1.5.2.

Based on observation and interview, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of National Fire Protection Association (NFPA) 25, and the 1999 edition of National Fire Protection Association (NFPA) 13. This can affect the operation of the heads by delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place all occupants at risk in the event of a fire in the Diagnostic Building.

Findings include:

Observation and interview on 12/14/11, revealed two missing escutcheon plates for sprinkler heads at the top of the Diagnostic stairwell. This was verified with Maintenance Staff A.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. NFPA 13, 12.1

NFPA Standard: The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. NFPA 25, 1-4.4

NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. NFPA 25, 2-2.1.1

Based on observations, the facility failed to maintain the emergency lighting in accordance National Fire Protection Association (NFPA) Standard 101, 2000 edition. This deficient practice affects all occupants in the facility.

Findings include:

Observations and interview on 12/13/11, revealed the emergency light by the Supervisors Office in the Witwer Children's Center did not illuminate when tested. This was corrected by maintenance staff during the inspection. Safety Staff A verified this observation at the time of the survey process.

Based on observation and interview, this facility is not maintaining and providing the sprinkler system in accordance with the 1998 edition of National Fire Protection Association (NFPA) 25, and the 1999 edition of National Fire Protection Association (NFPA) 13. This can affect the operation of the heads by delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place all occupants at risk in the event of a fire.

Findings include:

1. Observation and interview on 12/14/11, revealed one standard sprinkler head in 5 Center Nurse's Work Station surrounded by quick response sprinkler heads. The area that was sprinklered with different types of heads were not separated from each other. This was verified with Maintenance Staff A.

2. Observation and interview on 12/14/11, revealed the Linen Storage room in the Basement had green Intermediate temperature sprinkler heads throughout the room. This room was formerly the location of the Laundry, and now is used for Linen Storage. Maintenance Staff A verified this finding.

3. Observation and interview on 12/14/11, revealed the walkway from the Atrium to the OB building did not have sprinkler coverage. Maintenance Staff A verified this finding.


NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. NFPA 13, 12.1

NFPA Standard: The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. NFPA 25, 1-4.4

NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. NFPA 25, 2-2.1.1


NFPA Standard: When existing light hazard systems are converted to use quick-response sprinklers, all sprinklers in the compartmented space shall be changed. 1999 NFPA 13, 5-3.1.5.2.

Based on observation and interview, this facility is not maintaining the sprinkler system in accordance with the 1998 edition of National Fire Protection Association (NFPA) 25, and the 1999 edition of National Fire Protection Association (NFPA) 13. This can affect the operation of the heads by delaying the response time or preventing the operation of the heads that can compromise the effectiveness of the fire suppression system. This deficient practice can place all occupants at risk in the event of a fire in the Diagnostic Building.

Findings include:

Observation and interview on 12/14/11, revealed two missing escutcheon plates for sprinkler heads at the top of the Diagnostic stairwell. This was verified with Maintenance Staff A.

NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. NFPA 13, 12.1

NFPA Standard: The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. NFPA 25, 1-4.4

NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. NFPA 25, 2-2.1.1