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The facility failed to ensure complete two-hour fire rated wall assemblies.

Observation determined multiple unsealed penetrations through the two-hour fire rated walls throughout the buildings.

The deficiency affected six (6) of seven (7) two-hour fire walls that were reviewed.

The facility failed to ensure the appropriate building construction type.

Observation determined:

1) There were two (2) unsealed spaces around pipes that passed through the floor between the 5th floor B Wing Nurses Station and the B Wing Penthouse.

2) Fireproofing material was missing from structural steel in the following areas:

a) The I-beam on the ceiling of the 5th floor B Wing Old Medical Records Room.

b) The I-beams and columns in the basement B Wing Engineering Room, Mechanical Room, and Elevator Equipment Room.

The facility failed to ensure corridor doors were equipped with automatic latching hardware suitable for keeping the door closed and resistant to the passage of smoke.

Observation determined:
1. Eleven (11) of eleven (11) patient room doors in the North Wing of the second floor had a leaf door at the latching edge. There was a three-eighths inch gap between the meeting edges of the doors allowing the passage of smoke.

2. Fourteen (14) of nineteen (19) patient room doors in the East Wing of the second floor had an inactive leaf. The inactive leaf was not equipped with self-latching hardware suitable for keeping the door closed.

Failure to ensure corridor doors were equipped with self-latching hardware and resistant to the passage of smoke increases the risk of death or injury due to fire.

This deficiency affected twenty-five (25) of thirty (30) patient room doors on the second floor, north and east wings.

Note: This deficiency was corrected before the end of this survey.

The facility failed to maintain the two-hour fire resistive rating of elevator shaft enclosures.

Observation determined:

1) The B Wing elevator shaft was open to the elevator equipment room.

2) The walls of the B Wing elevator equipment room were not constructed as two-hour fire rated assemblies.

The deficiency affected one (1) of four (4) elevator shafts.

Note: The deficiency was corrected before the end of this survey.

The facility failed to provide an appropriate fire protection rating on door assemblies in vertical openings. 8.2.3.2.3.1.

Observation determined the latching hardware on the following stairwell doors was not fire rated hardware:

1) East B Wing Stairwell basement door.

2) East B Wing Stairwell 2nd floor door.

3) West B Wing Stairwell 2nd floor door.

4) East B Wing Stairwell 4th floor door.

5) West B Wing Stairwell 4th floor door.

6) East B Wing Stairwell 5th floor door.

7) West B Wing Stairwell 5th floor door.

8) South A Wing Stairwell 5th floor door.

The deficiency affected eight (8) of forty seven (47) stairwell doors.

Note: The deficiency was corrected before the end of this survey.

The facility failed to ensure smoke barriers were at least one-half hour fire resistant and smoke resistant.

Observation determined multiple unsealed penetrations through smoke barriers throughout the buildings.

The deficiency affected two (2) of four (4) smoke barriers that were reviewed.

The facility failed to ensure the fire alarm system was maintained, inspected and tested in accordance with NFPA 72 National Fire Alarm Code.

Review of the fire alarm test records indicated that the semiannual load voltage tests of the sealed lead acid batteries were not performed as required. The fire alarm system test records did not indicate load voltage tests of the sealed lead acid batteries semiannually.

The deficiency affected two (2) required load voltage tests of the batteries in the last year.

The Maintenance Director acknowledged the finding when the deficiency was identified.

Failure to test the fire alarm system as required increases the risk of death or injury due to fire.

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.

The deficiency affected two (2) of two (2) required load voltage tests of the batteries in the last year.

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.

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:

1) The northwest corner of the 5th floor C Wing east Storage Room lacked adequate sprinkler coverage.

2) The 1st floor B Wing Old MRI Storage Room had a sprinkler that was located 34 inches from the ceiling.

3) The basement C Wing Radiology Break Room had two (2) sprinklers that were closer than the minimum of six feet apart.

4) There was a hanging sign in the corridor by the Radiology Waiting Room in the basement C Wing that was obstructing sprinkler coverage.

The deficiency affected four (4) of numerous areas in the facility.

Note: The deficiency was corrected before the end of this survey.

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

On 5/08/14, no record of the required annual back flow preventer test was available.

The deficiency affected one of numerous required tests of the automatic sprinkler system.

Ref: 2000 NFPA 101 Section 18.3.5.1, 9.7.5, 1998 NFPA 25 Section 9-6.2

The facility failed to provide an occupancy separation having a one-hour fire resistance rating from the remainder of the building.

Observation determined the integrity of the one-hour wall between the ASC and the business occupancy exam rooms was compromised by:
1) Unsealed spaces around multiple pipe and conduit penetrations.2) Lack of fire caulk material at the head of wall.

3) Lack of fire caulk between the fireproofing on a beam and adjacent gypsum board.

Penetrations by pipes and conduits are required to be sealed with a material that is capable of maintaining the fire resistance of the occupancy separation wall.

The Maintenance employee acknowledged the finding when the deficiency was identified.

Failure to seal fire barriers as required increases the risk of death or injury due to fire.

The deficiency affected the entire ASC.

1) The facility failed to maintain the two-hour fire rated wall assemblies between the Roger Maris Clinic and Sanford Hospital. Observation determined:a) Multiple unsealed pipe and conduit penetrations through the two-hour occupancy separation wall. b) The head of wall had unsealed openings that were not sealed with approved fire caulk materials. Failure to maintain the integrity of the two-hour fire rated wall assembly increases the risk of death or injury due to fire. This deficiency affected one (1) of multiple compartments on the lower level.2) The facility failed to test the fire alarm system as required. Ref: 2000 NFPA 101 Section 19.3.4.1, 9.6.1.4; 1999 NFPA 72 table 7-3.2 item 6.d.3.Review of fire alarm system test records indicated the semiannual load voltage tests of the sealed lead acid batteries were not performed as required.Failure to test the fire alarm system as required increases the risk of death or injury due to fire. This deficiency affected two (2) of two (2) required load voltage tests of the batteries in the last year. 3) The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

On 5/08/14, no record of the required annual back flow preventer test was available.

The deficiency affected one of numerous required tests of the automatic sprinkler system.

Ref: 2000 NFPA 101 Section 18.3.5.1, 9.7.5, 1998 NFPA 25 Section 9-6.2. 4) The facility failed to perform the required inspection, testing and maintenance for six (6) of six (6) emergency generators. NFPA 110, Standard for Emergency and Standby Power Systems. Records review determined:
a) Weekly visual inspections of the emergency generators were not documented.b) Testing and documenting the value of the specific gravity of the generator batteries was not recorded. Failure to inspect and maintain the emergency generators in accordance with NFPA 110 increases the risk of death or injury due to fire.

This deficiency affected six (6) of six (6) emergency generators.

The facility failed to ensure the emergency generator was in compliance with NFPA 110, Standard for Emergency and Standby Power Systems.

Observation determined:

1) There was no remote stop switch for the A Wing penthouse generator located outside of the generator room.

2) There was no remote stop switch for the B Wing penthouse generator located outside of the generator room.

The deficiency affected two (2) of four (4) emergency generators.

Note: The deficiency was corrected before the end of this survey.

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 power strips and extension cords were used in place of permanent wiring throughout the facility.

Failure to ensure electrical wiring is in accordance with NFPA 70 requirements increases the risk of death or injury due to fire.

The deficiency affected the entire facility.