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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 complete two-hour fire rated wall assemblies between the hospital and an attached clinic.

Observation determined multiple unsealed penetrations through the 2-hr. fire rated wall separating the Hospital from the Roger Maris Clinic.

Failure to maintain the integrity of the 2-hr. fire rated wall assembly increases the risk of death or injury due to fire.

This deficiency affected two (2) of nine (9) smoke compartments on the lower level.

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 maintain the two-hour fire resistive rating of shaft enclosures throughout the building.

Observation determined an eighteen (18) inch round duct penetrating through the wall to the corridor from a vertical mechanical chase on the third floor. The duct was not equipped with a fire or smoke damper.

Failure to maintain a two-hour fire resistant rating of vertical openings increases the risk of death or injury due to fire.

This deficiency affected one (1) of numerous penetrations.

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 smoke barriers were at least one-half hour fire resistant and smoke resistant.

Observation determined:
1) Approximately ninety (90) feet of the smoke barrier near the Endoscopy Department on the lower level was not sealed at the head of wall with fire rated material.
2) A four (4) inch square hole was cut through smoke barrier (LL7) above the corridor doors.

Failure to ensure smoke barriers were at least one-half hour fire resistant and smoke resistant increases the risk of death or injury due to fire.

This deficiency affected two (2) of seven (7) smoke barriers on the lower level and two (2) of thirty-one (31) smoke barriers throughout the building.

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.

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.

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

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.

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.

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.

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 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.

Observation determined curtains in patient bathrooms were installed to the ceiling throughout the fourth and fifth floors, obstructing sprinkler coverage in the room. These curtains did not have mesh at the top 18".

Failure to ensure the automatic sprinkler system was maintained in a reliable operating condition increases the risk of death or injury due to fire.

This deficiency affected two (2) of seven (7) floors.

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

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.

1) The facility failed to ensure the fire alarm system was in compliance with NFPA 72, National Fire Alarm Code.

Review of records indicated that the fire alarm system was not tested on an annual basis. The most recent fire alarm system test was conducted on 8-05-11, which exceeds a 12-month period for annual testing of the fire alarm system.

The deficiency affected the entire building.


2) Visual inspection frequencies and specific testing and maintenance frequencies for smoke detection systems are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods.

Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years.

The facility failed to ensure smoke detectors were maintained, inspected and tested in accordance with NFPA 72.

Review of the fire alarm test results indicated the smoke detection system was not sensitivity tested at frequencies in compliance with the minimum requirements of NFPA 72.

On 5/12/14, there was no smoke detector sensitivity test record available.

The deficiency affected one (1) of numerous required tests of the smoke detection system.

1) Testing frequencies for automatic sprinkler systems range from quarterly to annually. Inspection frequencies can be as often as weekly to as long as annually. The frequencies for testing, inspection and maintenance of automatic sprinkler systems are dictated by the requirements as outlined by Table 5-1 of NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. NFPA 25 requires the facility to complete, maintain and make available to the authority having jurisdiction copies of records which indicate the procedure performed, by whom, the results and the date. These records are to be retained for the life of the system. The automatic sprinkler system is required to have specified maintenance.

Sprinkler record review determined the facility failed to conduct quarterly inspector tests and maintenance of the sprinkler system.

2) Visual inspection frequencies and specific testing and maintenance frequencies for smoke detection systems are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods.

Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years.

The facility failed to ensure smoke detectors were maintained, inspected and tested in accordance with the manufacturer's specifications.

Review of the fire alarm test records indicated the smoke detection system did not have sensitivity testing at frequencies in compliance with the minimum requirements of NFPA 72. The test records indicated the smoke detectors have not been tested for sensitivity.

Failure to test and inspect automatic sprinkler systems and fire alarm systems in accordance with NFPA 25 and NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected the entire facility.

1) The facility failed to inspect the emergency generator on a weekly basis.

Review of records did not indicate a weekly visual inspection of the emergency generators was done.


2) Maintenance of emergency generator batteries should include checking and recording the value of the specific gravity. NFPA 110, Section A-6-3.6

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

Review of documentation did not indicate the specific gravity of the batteries for the emergency generator was tested.

Failure to inspect and maintain the emergency generators in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

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

3) 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

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.

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

1) Visual inspection frequencies and specific testing and maintenance frequencies for smoke detection systems are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods.

Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years.

The facility failed to ensure smoke detectors were maintained, inspected and tested in accordance with the manufacturer's specifications.

Review of the records did not indicate the sensitivity of the smoke detectors has been tested.

Failure to maintain the smoke detectors in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected the entire smoke detection system.


2) Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system as required.

Observation determined the facility did not have any record of the required annual forward flow and performance test for the automatic sprinkler system backflow preventer.

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

The deficiency affected one of numerous test requirements of the automatic fire sprinkler system.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.5, 1998 NFPA 25 Section 9-6.2

3) Testing frequencies for automatic sprinkler systems range from quarterly to annually. Inspection frequencies can be as often as weekly to as long as annually. The frequencies for testing, inspection and maintenance of automatic sprinkler systems are dictated by the requirements as outlined by Table 5-1 of NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. NFPA 25 requires the facility to complete, maintain and make available to the authority having jurisdiction copies of records which indicate the procedure performed, by whom, the results and the date. These records are to be retained for the life of the system. The automatic sprinkler system is required to have specified maintenance.

The facility failed to test and inspect the automatic sprinkler system in accordance with NFPA 25.

Sprinkler record review determined the facility failed to conduct quarterly inspector tests and maintenance of the sprinkler system. The sprinkler system was tested and inspected semi-annually.

Failure to test the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

This deficiency affected two (2) of the previous four (4) required inspections.


4) The facility failed to inspect the emergency generator on a weekly basis.

Review of records did not indicate a weekly visual inspection of the generator.

Failure to inspect and maintain the emergency generators in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) emergency generators.


5) The facility failed to ensure the fire alarm system was in compliance with NFPA 72, National Fire Alarm Code.

Review of documentation determined the last inspection of the fire alarm system was done in May 2012. (twenty-four (24) months prior to this survey)

Failure to inspect and test the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected two (2) of two (2) previous required tests.

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.

1) Maintenance of emergency generator batteries should include checking and recording the value of the specific gravity. NFPA 110, Section A-6-3.6

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

Review of documentation did not indicate the specific gravity of the batteries for the emergency generator was tested.

Failure to inspect and maintain the emergency generators in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) emergency generator.

2) The facility failed to inspect the emergency generator on a weekly basis.

Review of records did not indicate a weekly visual inspection of the emergency generators was part of the required maintenance of the generator.

Failure to inspect and maintain the emergency generators in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) emergency generator.

1) The facility failed to inspect the emergency generator on a weekly basis.

Review of records did not indicate a weekly visual inspection of the emergency generators was completed.

2) Maintenance of emergency generator batteries should include checking and recording the value of the specific gravity. NFPA 110, Section A-6-3.6

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

Review of documentation did not indicate the specific gravity of the batteries for the emergency generator was tested.

Failure to inspect and maintain the emergency generators in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

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

Maintenance of emergency generator batteries should include checking and recording the value of the specific gravity. NFPA 110, Section A-6-3.6

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

Review of documentation did not indicate the specific gravity of the batteries for the emergency generator was tested.

Failure to inspect and maintain the emergency generators in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) emergency generators.

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.

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 complete two-hour fire rated wall assemblies between the hospital and an attached clinic.

Observation determined multiple unsealed penetrations through the 2-hr. fire rated wall separating the Hospital from the Roger Maris Clinic.

Failure to maintain the integrity of the 2-hr. fire rated wall assembly increases the risk of death or injury due to fire.

This deficiency affected two (2) of nine (9) smoke compartments on the lower level.

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 maintain the two-hour fire resistive rating of shaft enclosures throughout the building.

Observation determined an eighteen (18) inch round duct penetrating through the wall to the corridor from a vertical mechanical chase on the third floor. The duct was not equipped with a fire or smoke damper.

Failure to maintain a two-hour fire resistant rating of vertical openings increases the risk of death or injury due to fire.

This deficiency affected one (1) of numerous penetrations.

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 smoke barriers were at least one-half hour fire resistant and smoke resistant.

Observation determined:
1) Approximately ninety (90) feet of the smoke barrier near the Endoscopy Department on the lower level was not sealed at the head of wall with fire rated material.
2) A four (4) inch square hole was cut through smoke barrier (LL7) above the corridor doors.

Failure to ensure smoke barriers were at least one-half hour fire resistant and smoke resistant increases the risk of death or injury due to fire.

This deficiency affected two (2) of seven (7) smoke barriers on the lower level and two (2) of thirty-one (31) smoke barriers throughout the building.

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.

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.

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

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.

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.

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.

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 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.

Observation determined curtains in patient bathrooms were installed to the ceiling throughout the fourth and fifth floors, obstructing sprinkler coverage in the room. These curtains did not have mesh at the top 18".

Failure to ensure the automatic sprinkler system was maintained in a reliable operating condition increases the risk of death or injury due to fire.

This deficiency affected two (2) of seven (7) floors.

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

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.

1) The facility failed to ensure the fire alarm system was in compliance with NFPA 72, National Fire Alarm Code.

Review of records indicated that the fire alarm system was not tested on an annual basis. The most recent fire alarm system test was conducted on 8-05-11, which exceeds a 12-month period for annual testing of the fire alarm system.

The deficiency affected the entire building.


2) Visual inspection frequencies and specific testing and maintenance frequencies for smoke detection systems are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods.

Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years.

The facility failed to ensure smoke detectors were maintained, inspected and tested in accordance with NFPA 72.

Review of the fire alarm test results indicated the smoke detection system was not sensitivity tested at frequencies in compliance with the minimum requirements of NFPA 72.

On 5/12/14, there was no smoke detector sensitivity test record available.

The deficiency affected one (1) of numerous required tests of the smoke detection system.

1) Testing frequencies for automatic sprinkler systems range from quarterly to annually. Inspection frequencies can be as often as weekly to as long as annually. The frequencies for testing, inspection and maintenance of automatic sprinkler systems are dictated by the requirements as outlined by Table 5-1 of NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. NFPA 25 requires the facility to complete, maintain and make available to the authority having jurisdiction copies of records which indicate the procedure performed, by whom, the results and the date. These records are to be retained for the life of the system. The automatic sprinkler system is required to have specified maintenance.

Sprinkler record review determined the facility failed to conduct quarterly inspector tests and maintenance of the sprinkler system.

2) Visual inspection frequencies and specific testing and maintenance frequencies for smoke detection systems are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods.

Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years.

The facility failed to ensure smoke detectors were maintained, inspected and tested in accordance with the manufacturer's specifications.

Review of the fire alarm test records indicated the smoke detection system did not have sensitivity testing at frequencies in compliance with the minimum requirements of NFPA 72. The test records indicated the smoke detectors have not been tested for sensitivity.

Failure to test and inspect automatic sprinkler systems and fire alarm systems in accordance with NFPA 25 and NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected the entire facility.

1) The facility failed to inspect the emergency generator on a weekly basis.

Review of records did not indicate a weekly visual inspection of the emergency generators was done.


2) Maintenance of emergency generator batteries should include checking and recording the value of the specific gravity. NFPA 110, Section A-6-3.6

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

Review of documentation did not indicate the specific gravity of the batteries for the emergency generator was tested.

Failure to inspect and maintain the emergency generators in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

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

3) 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

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.

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

1) Visual inspection frequencies and specific testing and maintenance frequencies for smoke detection systems are dictated by the prescriptive requirements of NFPA 72, National Fire Alarm Code (Chapter 10-Inspection, Testing and Maintenance Tables 10.3.1, 10.4.2.2 and 10.4.3). This code identifies specific inspection, testing and maintenance frequencies and methods.

Sensitivity testing of smoke detectors is to be completed for all smoke detectors during the first year in service, and the alternate year following. After the second required calibration test, if the detector has remained within its listed and marked sensitivity range, the length of time between calibration tests may be extended, not to exceed five years.

The facility failed to ensure smoke detectors were maintained, inspected and tested in accordance with the manufacturer's specifications.

Review of the records did not indicate the sensitivity of the smoke detectors has been tested.

Failure to maintain the smoke detectors in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected the entire smoke detection system.


2) Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system as required.

Observation determined the facility did not have any record of the required annual forward flow and performance test for the automatic sprinkler system backflow preventer.

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

The deficiency affected one of numerous test requirements of the automatic fire sprinkler system.

Ref: 2000 NFPA 101 Section 19.3.5.1, 9.7.5, 1998 NFPA 25 Section 9-6.2

3) Testing frequencies for automatic sprinkler systems range from quarterly to annually. Inspection frequencies can be as often as weekly to as long as annually. The frequencies for testing, inspection and maintenance of automatic sprinkler systems are dictated by the requirements as outlined by Table 5-1 of NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. NFPA 25 requires the facility to complete, maintain and make available to the authority having jurisdiction copies of records which indicate the procedure performed, by whom, the results and the date. These records are to be retained for the life of the system. The automatic sprinkler system is required to have specified maintenance.

The facility failed to test and inspect the automatic sprinkler system in accordance with NFPA 25.

Sprinkler record review determined the facility failed to conduct quarterly inspector tests and maintenance of the sprinkler system. The sprinkler system was tested and inspected semi-annually.

Failure to test the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

This deficiency affected two (2) of the previous four (4) required inspections.


4) The facility failed to inspect the emergency generator on a weekly basis.

Review of records did not indicate a weekly visual inspection of the generator.

Failure to inspect and maintain the emergency generators in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) emergency generators.


5) The facility failed to ensure the fire alarm system was in compliance with NFPA 72, National Fire Alarm Code.

Review of documentation determined the last inspection of the fire alarm system was done in May 2012. (twenty-four (24) months prior to this survey)

Failure to inspect and test the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected two (2) of two (2) previous required tests.

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.

1) Maintenance of emergency generator batteries should include checking and recording the value of the specific gravity. NFPA 110, Section A-6-3.6

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

Review of documentation did not indicate the specific gravity of the batteries for the emergency generator was tested.

Failure to inspect and maintain the emergency generators in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) emergency generator.

2) The facility failed to inspect the emergency generator on a weekly basis.

Review of records did not indicate a weekly visual inspection of the emergency generators was part of the required maintenance of the generator.

Failure to inspect and maintain the emergency generators in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) emergency generator.

1) The facility failed to inspect the emergency generator on a weekly basis.

Review of records did not indicate a weekly visual inspection of the emergency generators was completed.

2) Maintenance of emergency generator batteries should include checking and recording the value of the specific gravity. NFPA 110, Section A-6-3.6

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

Review of documentation did not indicate the specific gravity of the batteries for the emergency generator was tested.

Failure to inspect and maintain the emergency generators in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

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

Maintenance of emergency generator batteries should include checking and recording the value of the specific gravity. NFPA 110, Section A-6-3.6

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

Review of documentation did not indicate the specific gravity of the batteries for the emergency generator was tested.

Failure to inspect and maintain the emergency generators in accordance with NFPA 99 and NFPA 110 increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) emergency generators.

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.