HospitalInspections.org

19.1.6.2, NFPA 101, LIFE SAFETY CODE
Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)

8.2.1, NFPA 101, LIFE SAFETY CODE
Construction: Buildings or structures occupied or used in accordance with the individual occupancy chapters (Chapters 12 through 42) shall meet the minimum construction requirements of those chapters. NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification...

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on observation and interview the facility failed to properly maintain the applied fireproof coating used to protect steel.

Findings include:

Observation during tour between the morning of 11/8/12 and the morning of 11/9/12 with Staff B (Facility Management Director) and Staff C (Maintenance) revealed the following:

1. Fourth floor, Mechanical Room M: At least three portions of exposed (unprotected) steel beams consisting of one area measuring approximately 6 feet by 6 inches, one area measuring approximately 1 foot by 4 feet, and one area measuring approximately 6 inches by 12 feet.

2. Fourth floor, Mechanical Room K: At least 5 areas of patching measuring greater than 144 square inches in area applied to beams and/or columns.

3. Ground floor, G Building, Electrical Room: At least one steel beam with at least 2 feet by 3 inches of exposed (unprotected) steel.

Interview during tour between 11/8/12 and 11/9/12 with Staff B and Staff C confirmed the areas of unprotected steel and confirmed that the areas of patching were hand toweled and not done in accordance with manufacturers specifications which state that areas being treated with the fireproofing in excess of 144 square inches must be spray applied as opposed to hand toweled.

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19.1.1.4.2, NFPA 101,LIFE SAFETY CODE
Communicating openings in dividing fire barriers... shall be permitted only in corridors and shall be protected by approved self-closing fire doors. (See also Section 8.2.)

19.3.7.3, NFPA 101, LIFE SAFETY CODE
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

8.2.2.2, NFPA 101, LIFE SAFETY CODE
Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.

8.3.2, NFPA 101, LIFE SAFETY CODE
Continuity: Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

8.2.3.2.4.2, NFPA 101, LIFE SAFETY CODE
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

8.3.6.1, NFPA 101, LIFE SAFETY CODE
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on interview, observation, and record review the facility failed to ensure that all fire and smoke barrier penetrations are properly protected.

Findings include:

Interview and record review of facility floor plans during tour between 11/7/12 and 11/9/12 with Staff B (Facility Management Director) revealed the locations of fire barriers and smoke barriers throughout the facility.

Observation during tour on 11/8/12 between 2:15 p.m. and 2:45 p.m. with Staff B and Staff C (Maintenance) revealed the following fire barriers have unprotected penetrations:

1. OMS Waiting Room: The fire barrier separation has at least one unprotected penetration.

2. First floor, Pavilion entrance: The fire barrier separation has at least one unprotected penetration caused by security cables.

3. Third floor, M Building, Labor and Delivery: The smoke barrier separation has at least one unprotected penetration.

4. Second floor, I Building, ICU consulting near smoke door #230: The smoke barrier has at least one unprotected penetration.

Interview during tour on 11/8/12 with Staff B and Staff C confirmed the findings at the time of discovery.

19.3.5.1, NFPA 101, LIFE SAFETY CODE
Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

9.7.1.1, NFPA 101, LIFE SAFETY CODE
Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

9.7.5, NFPA 101, LIFE SAFETY CODE
Maintenance and Testing: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

5-1.1, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

5-5.3.4, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Minimum Distance Between Sprinklers: A minimum distance shall be maintained between sprinklers to prevent operating sprinklers from wetting adjacent sprinklers and to prevent skipping of sprinklers. The minimum distance permitted between sprinklers shall comply with the value indicated in the section for each type or style of sprinkler.

5-6.5.1.2, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Sprinklers shall be arranged to comply with... Table 5-6.5.1.2
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP):

Distance from Sprinklers to Side of Obstruction: Less than 1 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 0

Distance from Sprinklers to Side of Obstruction: 1 ft to less than 1 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 2-1/2

Distance from Sprinklers to Side of Obstruction: 1 ft 6 in. to less than 2 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 3-1/2

Distance from Sprinklers to Side of Obstruction: 2 ft to less than 2 ft 6 in.

Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 5-1/2

Distance from Sprinklers to Side of Obstruction: 2 ft 6 in. to less than 3 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 7-1/2

Distance from Sprinklers to Side of Obstruction: 3 ft to less than 3 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 9-1/2

Distance from Sprinklers to Side of Obstruction: 3 ft 6 in. to less than 4 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 12

Distance from Sprinklers to Side of Obstruction: 4 ft to less than 4 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 14

Distance from Sprinklers to Side of Obstruction: 4 ft 6 in. to less than 5 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 16-1/2

Distance from Sprinklers to Side of Obstruction: 5 ft and greater
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 18

2-2.1.1, NFPA 25, WATER-BASED FIRE PROTECTION SYSTEMS
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.

2-1, NFPA 25, WATER-BASED FIRE PROTECTION SYSTEMS
General: This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. Table 2-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Item: Obstruction investigation
Activity: Maintenance
Frequency: 5 years or as needed
Reference: Chapter 10

10-2.2, NFPA 25, WATER-BASED FIRE PROTECTION SYSTEMS
Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.

Based on record review, observation, and interview the facility failed to ensure that all sprinkler systems are properly maintained.

Findings include:

Record review of sprinkler vendor records during tour on 11/6/12 between 1:30 p.m.and 3:30 p.m. revealed that there are no test results for the obstruction test of the dry pipe sprinkler systems.

Observation during tour on 11/8/12 between 11:00 a.m. and 1:00 p.m. with Staff B (Facility Management Director) and Staff C (Maintenance) revealed the following:

1. Fourth floor, Pathway wing, housekeeping closet: One sidewall sprinkler head installed within approximately 4 feet of a pendent sprinkler head.

2. Third floor, Labor and Delivery wing: At least one pendent sprinkler head where the spray pattern of the head is partially obstructed by a soffit. The deflector of the sprinkler head is approximately 2 inches from the ceiling, the sprinkler head is less than 18 inches from a 12 inch soffit installed on the ceiling.

Interview during tour between 11/8/12 and 11/9/12 with Staff B and Staff C confirmed the findings of the sprinkler heads at the time of discovery and confirmed that the obstruction test for one of the facility's dry pipe sprinkler systems has not been conducted.

19.3.2.6, NFPA 101, LIFE SAFETY CODE
Cooking Facilities: Cooking facilities shall be protected in accordance with 9.2.3.

9.2.3, NFPA 101, LIFE SAFETY CODE
Commercial Cooking Equipment: Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

7-2.2.1, NFPA 96, VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS
Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer ' s instructions, and the following standards where applicable.
(a) NFPA 12, Standard on Carbon Dioxide Extinguishing Systems
(b) NFPA 13, Standard for the Installation of Sprinkler Systems
(c) NFPA 17, Standard for Dry Chemical Extinguishing Systems
(d) NFPA 17A, Standard for Wet Chemical Extinguishing Systems

9-2.1, NFPA 17, Dry Chemical Extinguishing Systems
On a monthly basis, inspection shall be conducted in accordance with the manufacturer ' s listed installation and maintenance manual or owner ' s manual. As a minimum, this " quick check " or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on record review, observation, and interview the facility failed to ensure that the hood suppression system is inspected on a monthly basis by facility personnel.

Findings include:

Record review of facility reports during tour on 11/6/12 between 1:30 p.m. and 3:30 p.m. revealed that no documentation is present to demonstrate that monthly inspections of the hood suppression system in the main kitchen has been conducted.

Observation during tour on 11/9/12 between 9:30 a.m. and 1:30 p.m. with Staff B (Facility Management Director) and Staff C (Maintenance) revealed that the inspection tag for the suppression system in the main kitchen has no record of monthly inspections having been completed.

Interview during tour on 11/9/12 with Staff B confirmed the findings.

4-3.5.2.1, NFPA 99, HEALTH CARE FACILITIES
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

4-5.1.1.1, NFPA 99, HEALTH CARE FACILITIES
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Based on observation the facility failed to ensure the proper storage of medical gas cylinders.

Findings include:

Observation during tour on 11/9/12 with Staff B (Facility Management Director) and Staff C (Maintenance) revealed that the Nitrogen storage room and Nitrous Oxide storage rooms located on the ground floor in Building L each have at least 10 cylinders secured with a single chain.

19.1.6.2, NFPA 101, LIFE SAFETY CODE
Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)

8.2.1, NFPA 101, LIFE SAFETY CODE
Construction: Buildings or structures occupied or used in accordance with the individual occupancy chapters (Chapters 12 through 42) shall meet the minimum construction requirements of those chapters. NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification...

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on observation and interview the facility failed to properly maintain the applied fireproof coating used to protect steel.

Findings include:

Observation during tour between the morning of 11/8/12 and the morning of 11/9/12 with Staff B (Facility Management Director) and Staff C (Maintenance) revealed the following:

1. Fourth floor, Mechanical Room M: At least three portions of exposed (unprotected) steel beams consisting of one area measuring approximately 6 feet by 6 inches, one area measuring approximately 1 foot by 4 feet, and one area measuring approximately 6 inches by 12 feet.

2. Fourth floor, Mechanical Room K: At least 5 areas of patching measuring greater than 144 square inches in area applied to beams and/or columns.

3. Ground floor, G Building, Electrical Room: At least one steel beam with at least 2 feet by 3 inches of exposed (unprotected) steel.

Interview during tour between 11/8/12 and 11/9/12 with Staff B and Staff C confirmed the areas of unprotected steel and confirmed that the areas of patching were hand toweled and not done in accordance with manufacturers specifications which state that areas being treated with the fireproofing in excess of 144 square inches must be spray applied as opposed to hand toweled.

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19.1.1.4.2, NFPA 101,LIFE SAFETY CODE
Communicating openings in dividing fire barriers... shall be permitted only in corridors and shall be protected by approved self-closing fire doors. (See also Section 8.2.)

19.3.7.3, NFPA 101, LIFE SAFETY CODE
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

8.2.2.2, NFPA 101, LIFE SAFETY CODE
Fire compartments shall be formed with fire barriers that are continuous from outside wall to outside wall, from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Walls used as fire barriers shall comply with Chapter 3 of NFPA 221, Standard for Fire Walls and Fire Barrier Walls. The NFPA 221 limitation on percentage width of openings shall not apply.

8.3.2, NFPA 101, LIFE SAFETY CODE
Continuity: Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

8.2.3.2.4.2, NFPA 101, LIFE SAFETY CODE
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Insulation and coverings for pipes and ducts shall not pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.
(4) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

8.3.6.1, NFPA 101, LIFE SAFETY CODE
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on interview, observation, and record review the facility failed to ensure that all fire and smoke barrier penetrations are properly protected.

Findings include:

Interview and record review of facility floor plans during tour between 11/7/12 and 11/9/12 with Staff B (Facility Management Director) revealed the locations of fire barriers and smoke barriers throughout the facility.

Observation during tour on 11/8/12 between 2:15 p.m. and 2:45 p.m. with Staff B and Staff C (Maintenance) revealed the following fire barriers have unprotected penetrations:

1. OMS Waiting Room: The fire barrier separation has at least one unprotected penetration.

2. First floor, Pavilion entrance: The fire barrier separation has at least one unprotected penetration caused by security cables.

3. Third floor, M Building, Labor and Delivery: The smoke barrier separation has at least one unprotected penetration.

4. Second floor, I Building, ICU consulting near smoke door #230: The smoke barrier has at least one unprotected penetration.

Interview during tour on 11/8/12 with Staff B and Staff C confirmed the findings at the time of discovery.

19.3.5.1, NFPA 101, LIFE SAFETY CODE
Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

9.7.1.1, NFPA 101, LIFE SAFETY CODE
Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

9.7.5, NFPA 101, LIFE SAFETY CODE
Maintenance and Testing: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

5-1.1, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

5-5.3.4, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Minimum Distance Between Sprinklers: A minimum distance shall be maintained between sprinklers to prevent operating sprinklers from wetting adjacent sprinklers and to prevent skipping of sprinklers. The minimum distance permitted between sprinklers shall comply with the value indicated in the section for each type or style of sprinkler.

5-6.5.1.2, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Sprinklers shall be arranged to comply with... Table 5-6.5.1.2
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP):

Distance from Sprinklers to Side of Obstruction: Less than 1 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 0

Distance from Sprinklers to Side of Obstruction: 1 ft to less than 1 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 2-1/2

Distance from Sprinklers to Side of Obstruction: 1 ft 6 in. to less than 2 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 3-1/2

Distance from Sprinklers to Side of Obstruction: 2 ft to less than 2 ft 6 in.

Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 5-1/2

Distance from Sprinklers to Side of Obstruction: 2 ft 6 in. to less than 3 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 7-1/2

Distance from Sprinklers to Side of Obstruction: 3 ft to less than 3 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 9-1/2

Distance from Sprinklers to Side of Obstruction: 3 ft 6 in. to less than 4 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 12

Distance from Sprinklers to Side of Obstruction: 4 ft to less than 4 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 14

Distance from Sprinklers to Side of Obstruction: 4 ft 6 in. to less than 5 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 16-1/2

Distance from Sprinklers to Side of Obstruction: 5 ft and greater
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 18

2-2.1.1, NFPA 25, WATER-BASED FIRE PROTECTION SYSTEMS
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.

2-1, NFPA 25, WATER-BASED FIRE PROTECTION SYSTEMS
General: This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. Table 2-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Item: Obstruction investigation
Activity: Maintenance
Frequency: 5 years or as needed
Reference: Chapter 10

10-2.2, NFPA 25, WATER-BASED FIRE PROTECTION SYSTEMS
Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.

Based on record review, observation, and interview the facility failed to ensure that all sprinkler systems are properly maintained.

Findings include:

Record review of sprinkler vendor records during tour on 11/6/12 between 1:30 p.m.and 3:30 p.m. revealed that there are no test results for the obstruction test of the dry pipe sprinkler systems.

Observation during tour on 11/8/12 between 11:00 a.m. and 1:00 p.m. with Staff B (Facility Management Director) and Staff C (Maintenance) revealed the following:

1. Fourth floor, Pathway wing, housekeeping closet: One sidewall sprinkler head installed within approximately 4 feet of a pendent sprinkler head.

2. Third floor, Labor and Delivery wing: At least one pendent sprinkler head where the spray pattern of the head is partially obstructed by a soffit. The deflector of the sprinkler head is approximately 2 inches from the ceiling, the sprinkler head is less than 18 inches from a 12 inch soffit installed on the ceiling.

Interview during tour between 11/8/12 and 11/9/12 with Staff B and Staff C confirmed the findings of the sprinkler heads at the time of discovery and confirmed that the obstruction test for one of the facility's dry pipe sprinkler systems has not been conducted.

19.3.2.6, NFPA 101, LIFE SAFETY CODE
Cooking Facilities: Cooking facilities shall be protected in accordance with 9.2.3.

9.2.3, NFPA 101, LIFE SAFETY CODE
Commercial Cooking Equipment: Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

7-2.2.1, NFPA 96, VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS
Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer ' s instructions, and the following standards where applicable.
(a) NFPA 12, Standard on Carbon Dioxide Extinguishing Systems
(b) NFPA 13, Standard for the Installation of Sprinkler Systems
(c) NFPA 17, Standard for Dry Chemical Extinguishing Systems
(d) NFPA 17A, Standard for Wet Chemical Extinguishing Systems

9-2.1, NFPA 17, Dry Chemical Extinguishing Systems
On a monthly basis, inspection shall be conducted in accordance with the manufacturer ' s listed installation and maintenance manual or owner ' s manual. As a minimum, this " quick check " or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

4.6.12.1, NFPA 101, LIFE SAFETY CODE
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Based on record review, observation, and interview the facility failed to ensure that the hood suppression system is inspected on a monthly basis by facility personnel.

Findings include:

Record review of facility reports during tour on 11/6/12 between 1:30 p.m. and 3:30 p.m. revealed that no documentation is present to demonstrate that monthly inspections of the hood suppression system in the main kitchen has been conducted.

Observation during tour on 11/9/12 between 9:30 a.m. and 1:30 p.m. with Staff B (Facility Management Director) and Staff C (Maintenance) revealed that the inspection tag for the suppression system in the main kitchen has no record of monthly inspections having been completed.

Interview during tour on 11/9/12 with Staff B confirmed the findings.

4-3.5.2.1, NFPA 99, HEALTH CARE FACILITIES
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

4-5.1.1.1, NFPA 99, HEALTH CARE FACILITIES
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Based on observation the facility failed to ensure the proper storage of medical gas cylinders.

Findings include:

Observation during tour on 11/9/12 with Staff B (Facility Management Director) and Staff C (Maintenance) revealed that the Nitrogen storage room and Nitrous Oxide storage rooms located on the ground floor in Building L each have at least 10 cylinders secured with a single chain.