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Based on observation and interview, the facility failed to ensure sprinkler heads were maintained per the requirements of:
2012 NFPA 101 Sections 19.3.5, 9.7.1.1, 9.7.5, 19.7.6, 4.6.12
2010 NFPA 13: 6.2.9.2, 6.2.9.5
2011 NFPA 25 Section 5.2.1.4.
This deficiency affected 1 of 3 smoke compartments.
The findings include:
Observation on 12/19/2017 at 12:54 PM, confirmed the facility had quick response sprinklers in the entry alcove to the Omni cell room, Clean linen and soiled linen room and did not have spares in the sprinkler head cabinet.
The Site Manager of Engineering was present when the deficiencies were identified and acknowledged by the Administrator during the exit conference on 12/19/2017.

Based on observation and interview, the facility failed to maintain fire walls per the requirements of 2012 NFPA 101, 19.7.6, 4.6.12, 8.3.5.1.
This deficiency affected 2 of 3 smoke compartments.
The findings include:
Observation and interview with the Site Manager of Engineering , on 12/19/2017 at 1:10 PM confirmed an improperly sealed penetration in a 2-hour fire wall above the corridor horizontal exit fire doors by the physicians on-call room, There was numerous low voltage wiring passing through a sleeved collar in a gypsum wall. No UL firestop system could be provided for this penetration.
The Site Manager of Engineering was present when the deficiencies were identified and acknowledged by the Administrator during the exit conference on 12/19/2017.