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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. NFPA 101 Life Safety Code, 4.6.12.1.

The facility failed to ensure the electrical wiring was maintained in accordance with NFPA 70 National Electrical Code, 2011 Edition. Section 4.8.

Observation determined an electrical powerstrip was used in place of permanent wiring to provide electricity to a refrigerator in the Pharmacy.Flexible cords and cables shall not be used for the following:
(a) As a substitute for the fixed wiring of a structure.
(b) Where run through holes in walls, structural ceilings,suspended ceilings, dropped ceilings, or floors.
(c) Where run through doorways, windows, or similar openings.
(d) Where attached to building surfaces.Failure to ensure temporary wiring is not used in place of permanent wiring increases the risk of injury and death due to fire. This deficiency affected the Pharmacy.2) 2) The facility failed to ensure the proper position of suspended ceiling tiles in areas protected by the automatic fire sprinkler system. (Heat from a fire stratifies to the suspended ceiling and travels along the suspended ceiling to activate the sprinkler. When suspended ceiling tiles are missing or damaged, it delays the activation of the automatic fire sprinkler system.)

Observation determined an egg crate grille was used in place of a ceiling tile between the two (2) doors into the facility at the employee entrance.

Failure to ensure the placement and proper position of suspended ceiling tiles in areas protected by the automatic fire sprinkler system increases the risk of injury and death due to fire.

This deficiency affected one (1) of one (1) smoke compartment in the building.

The facility failed to maintain a two-hour fire resistance-rated occupancy separation between the hospital of Type II (222) construction and the attached clinic of Type II (000) construction. Observation determined a renovation of the west two-hour fire-rated occupancy separation was completed. This included:1) Installation of a door and frame with no fire protection rating. 2) Failure to seal openings around a through-wall penetration by a copper pipe.3) Failure to seal the head-of -wall joint at the top of the wall between the deck and the gypsum board with approved fire sealant. 4) Failure to fire tape the gypsum board joints and screw heads. Failure to maintain the integrity of the two-hour-fire rated occupancy separation increases the risk of death or injury due to fire.This deficiency affected the entire first floor.

The facility failed to ensure exit access was readily accessible at all times. Doors are required to be arranged to be opened readily from the egress side. Locks, if provided, shall not require the use of special knowledge or effort for operation from the egress side. Observation determined two (2) of two (2) stair access doors from the second floor (patient care) were equipped with access-controlled magnetic locks that lock when an infant from the adjacent Birthing Center approaches either door equipped with a magnetic lock. There is no means to manually release the lock without a card for the card reader. The doors were not equipped with a delayed egress feature. The deficiency affected egress to two (2) of two (2) stair exits from the second floor.

Failure to ensure exit access is readily available at all times increases the risk of death or injury due to fire.This deficiency affected two (2) of two (2) smoke compartments on the second floor.

Smoke detectors must not be located in a direct airflow nor closer than 3 ft. (1 m) from an air supply diffuser or return air opening. 19.3.4.5.1, 9.6.2.10.1.1, NFPA 72 17.7.4.1.

The facility failed to ensure the smoke detection system was in compliance with NFPA 72, National Fire Alarm Code.

Observation determined numerous smoke detectors throughout the facility were installed within 3 ft. of an air supply diffuser or air supply vent.

Failure to install the smoke detection system as required increases the risk of death or injury due to fire.

This deficiency affected numerous smoke detectors in the facility. The smoke detection system serves the entire facility.

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.

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 is dictated by the requirements as outlined in NFPA 25. 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.

Observation determined a sprinkler in the Radiology Control Room was missing the escutcheon plate. Failure to inspect and perform maintenance on the automatic fire sprinkler system increases the risk of injury and death due to fire.This deficiency affected one (1) of three (3) smoke compartments.

The facility failed to ensure one (1) of one (1) smoke barrier was smoke resisting and had at least a one-half hour fire resistance rating.
Observation determined unsealed openings around conduits were not sealed with fire rated materials in the following locations:1) Unsealed spaces around two (2) through-wall conduit penetrations on the east side of the barrier above the south corridor smoke barrier doors. 2) Unsealed spaces around one (1) through-wall conduit penetration on the west side of the barrier above the south corridor smoke barrier doors. Failure to maintain smoke barriers as required increases the risk of death or injury due to fire.

The deficiency affected two (2) of three (3) smoke compartments in the building.

The facility failed to provide a documented risk assessment of building systems. NFPA 99, 4.2. Review of documentation and interview of staff determined the facility failed to conduct and document a risk assessment of building systems. Failure to conduct a risk assessment of building systems increases the risk of injury or death due to fire. This deficiency affected building systems throughout the entire facility.

Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted. NFPA 110, Standard for Emergency and Standby Power Systems. 8.3.7.1. The facility failed to ensure the maintenance and testing of the emergency batteries was in compliance with NFPA 110. The facility failed to inspect two (2) of two (2) emergency generators. Maintenance of emergency generator batteries must include checking and recording the value of the specific gravity. Review of records indicated a weekly visual inspection of the emergency generators was completed but lacked documentation of checking and recording the value of the specific gravity.

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 two (2) of two (2) emergency generators.