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CFR(s): NFPA 101

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure,
or horizontal exit, smoke barrier, or hazardous
area enclosure are self-closing and kept in the
closed position, unless held open by a release
device complying with 7.2.1.8.2 that automatically
closes all such doors throughout the smoke
compartment or entire facility upon activation of:
% Required manual fire alarm system; and
% Local smoke detectors designed to detect
smoke passing through the opening or a required
smoke detection system; and
% Automatic sprinkler system, if installed; and
% Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8
This STANDARD is not met as evidenced by:
K 223
The inspector observed, while accompanied by
The COO, safety manager, director of the
business operation, director of the facilities
management &planning, facility manager and
maintenance personnel, during the hours of the
inspection from 01:40 PM to 06:30 PM on
10/24/2018 that there were the following issues.
They were the following issues.
A) The smoke barrier compartment double
egress doors were not fully closed to prevent
smoke passage.

CFR(s): NFPA 101
Electrical Systems - Other
List in the REMARKS section any NFPA 99
Chapter 6 Electrical Systems requirements that
are not addressed by the provided K-Tags, but
are deficient. This information, along with the
applicable Life Safety Code or NFPA standard
citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
This STANDARD is not met as evidenced by:
The inspector observed, while accompanied by
The COO, safety manager, director of the
business operation, director of the facilities
management &planning, facility manager and
maintenance personnel, during the hours of the
inspection from 01:40 PM to 06:30 PM on
10/24/2018 that there were the following issues.
They were the following issues.
(A) There was a missing receptacle powered
from life safety branch at the generator set
location. This is not in accordance with NFPA 99,
1999: 3-4.2.2.2.(b)5. "The emergency generator
location shall have task illumination, battery
charger for emergency battery powered lighting
unit(s), and selected receptacles at the generator
set location and essential automatic transfer
switch location"

CFR(s): NFPA 101
Gas Equipment - Other
List in the REMARKS section any NFPA 99
Chapter 11 Gas Equipment requirements that are
not addressed by the provided K-Tags, but are
deficient. This information, along with the
applicable Life Safety Code or NFPA standard
citation, should be included on Form CMS-2567.
Chapter 11 (NFPA 99)
This STANDARD is not met as evidenced by:
K 922
The inspector observed, while accompanied by
The COO, safety manager, director of the
business operation, director of the facilities
management &planning, facility manager and
maintenance personnel during the hours of the
inspection from 01:40 PM to 06:30 PM on
10/24/2018 that there were the following issues.
They were the following issues.
A) There was not a dedicated mechanical
exhaust system that draw air from within 1 foot of
the floor and operate continuously inside the
medical storage rooms or natural ventilation
provided at 72 sq. ft. within 12" of ceiling and at
72 sq. ft. within 12" of the floor. This does not
comply with NFPA 99 as followed: Re. NFPA 99,
2002: 5.1.3.3.3.1(E). Where the total volume of
medical gases connected and in storage is less
than 3000 cu.ft. at STP, natural ventilation shall
be permitted - NFPA 99, 2002: 5.1.3.3.1(D).
Where natural ventilation is permitted, it shall
consist of two louvered openings, each having a
minimum free area of 72 in. sq., with one located
within 1 ft. of the floor and one located within 1 ft.
of the ceiling. Re. NFPA 99, 2002:
5.1.3.3.3.1(B). - Where the total volume of
medical gases connected and in storage is
greater than 3,000 cu.ft. at STP, indoor supply
locations shall be provided with dedicated
mechanical ventilation systems th