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Based on observation and staff interview, the facility failed to ensure corridor walls were smoke resistant in 1 of 7 smoke compartments. The findings were:

Observation of the corridor walls above the drop down ceiling adjacent to the main pharmacy on 12/16/15 at 10:45 AM revealed a 12" X 12" penetration from pipes, and duct work penetrating the corridor wall. Further observation revealed the corridor walls were constructed to extend from floor to roof deck. At the time of the observation the Facility Maintenance Manager acknowledged the penetrations.

Ref:
2000 NFPA 101, Section 19.3.6.2.1

Based on observation and staff interview, the facility failed to provide approved exit signs were the exit was not obvious and clearly identifiable. The findings were:

Observation of the direction of travel of the corridor adjacent to the ICU on 12/16/15 at 10:01 AM revealed the means of egress had been modified to accommodate construction currently being performed at the facility. Occupants would be required to exit the corridor into the ICU, utilizing the exit located within the unit. Further observation revealed an exit sign was not present in the corridor, marking the new means of egress. At the time of the observation the Facility Maintenance Manager acknowledged the exit in the corridor had been closed, and the new exit required occupants to exit the building from an adjacent room.

Ref:
2000 NFPA 101, Sections 19.7.9.1, 19.7.9.2, 4.6.10.1, 19.2.10.1 and 7.10.1.2

Based on document review and staff interview, the facility failed to provide documentation identifying certification of the central station fire alarm system in accordance with NFPA 72. The finding were:

Document review on 12/16/15 at 10:10 AM revealed the central station fire alarm system UL certificate was not posted at or near the station. Interview with the Facility Maintenance Manager at the time of the review acknowledged the certificate was not posted, and was unaware of the requirement.

Ref:
2000 NFPA 101, Sections 19.3.4.1 and 9.6.1.4
1999 NFPA 72, Section 1-6.2.3.1.1

Based on observation and staff interview, the facility failed to ensure that automatic sprinkler systems are installed, and continuously maintained per the requirements of NFPA 13 and NFPA 25. The finding were:

Observation of the sprinkler riser room on 12/16/15 at 9:20 AM revealed the fire riser had been modified from the original installation for the addition of a reduce pressure principle backflow preventer and valves. No hydraulic design information sign was provided. At the time of the observation the Facility Maintenance Manager acknowledged the required information was not present.

Ref:
2000 NFPA 101, Sections 19.3.5.1 and 9.7.1.1
1999 NFPA 13, Sections 5-15.4.6.2 and 10-5

Based on observation and staff interview, the facility failed to ensure corridor walls were smoke resistant in 1 of 7 smoke compartments. The findings were:

Observation of the corridor walls above the drop down ceiling adjacent to the main pharmacy on 12/16/15 at 10:45 AM revealed a 12" X 12" penetration from pipes, and duct work penetrating the corridor wall. Further observation revealed the corridor walls were constructed to extend from floor to roof deck. At the time of the observation the Facility Maintenance Manager acknowledged the penetrations.

Ref:
2000 NFPA 101, Section 19.3.6.2.1

Based on observation and staff interview, the facility failed to provide approved exit signs were the exit was not obvious and clearly identifiable. The findings were:

Observation of the direction of travel of the corridor adjacent to the ICU on 12/16/15 at 10:01 AM revealed the means of egress had been modified to accommodate construction currently being performed at the facility. Occupants would be required to exit the corridor into the ICU, utilizing the exit located within the unit. Further observation revealed an exit sign was not present in the corridor, marking the new means of egress. At the time of the observation the Facility Maintenance Manager acknowledged the exit in the corridor had been closed, and the new exit required occupants to exit the building from an adjacent room.

Ref:
2000 NFPA 101, Sections 19.7.9.1, 19.7.9.2, 4.6.10.1, 19.2.10.1 and 7.10.1.2

Based on document review and staff interview, the facility failed to provide documentation identifying certification of the central station fire alarm system in accordance with NFPA 72. The finding were:

Document review on 12/16/15 at 10:10 AM revealed the central station fire alarm system UL certificate was not posted at or near the station. Interview with the Facility Maintenance Manager at the time of the review acknowledged the certificate was not posted, and was unaware of the requirement.

Ref:
2000 NFPA 101, Sections 19.3.4.1 and 9.6.1.4
1999 NFPA 72, Section 1-6.2.3.1.1

Based on observation and staff interview, the facility failed to ensure that automatic sprinkler systems are installed, and continuously maintained per the requirements of NFPA 13 and NFPA 25. The finding were:

Observation of the sprinkler riser room on 12/16/15 at 9:20 AM revealed the fire riser had been modified from the original installation for the addition of a reduce pressure principle backflow preventer and valves. No hydraulic design information sign was provided. At the time of the observation the Facility Maintenance Manager acknowledged the required information was not present.

Ref:
2000 NFPA 101, Sections 19.3.5.1 and 9.7.1.1
1999 NFPA 13, Sections 5-15.4.6.2 and 10-5