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19.3.6.3.4, NFPA 101, LIFE SAFETY CODE
Door-closing devices shall not be required on doors in corridor wall openings other than those serving required exits, smoke barriers, or enclosures of vertical openings and hazardous areas.

19.3.6.3.3, NFPA 101, LIFE SAFETY CODE
Hold-open devices that release when the door is pushed or pulled shall be permitted.

A.19.3.6.3.3, NFPA 101, LIFE SAFETY CODE
Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

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 ensure that doors with self-closing devices are not obstructed from use.

Findings include:

Observation during tour on 11/3/11 at approximately 3:30 p.m. with Staff B (Physical Plant Manager) revealed that room 138 in Med. Surg. located on the main floor is being used for storage of Geri-chairs where the storage prevents the door from closing.

Interview during tour on 11/3/11 with Staff B revealed that the door is an automatic closing door that releases when the fire alarm activates and confirmed the findings.

19.3.7.6, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.

8.3.4.3, NFPA 101, LIFE SAFETY CODE
Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

19.2.2.2.6, NFPA 101, LIFE SAFETY CODE
Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

A.19.2.2.2.6, NFPA 101, LIFE SAFETY CODE
It is desirable to keep doors in exit passageways, stair enclosures, horizontal exits, smoke barriers, and required enclosures around hazardous areas closed at all times to impede the travel of smoke and fire gases. Functionally, however, this involves decreased efficiency and limits patient supervision by the staff of a facility. To accommodate such needs, it is practical to presume that such doors will be kept open, even to the extent of employing wood chocks and other makeshift devices. Doors in exit passageways, horizontal exits, and smoke barriers should, therefore, be equipped with automatic hold-open devices actuated by the methods described regardless of whether the original installation of the doors was predicated on a policy of keeping them closed.

7.2.1.8.1, NFPA 101, LIFE SAFETY CODE
A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

7.2.1.8.2, NFPA 101, LIFE SAFETY CODE
In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Based on record review, interview, and observation the facility failed to ensure that smoke barrier doors are not secured in the open position.

Findings include:

Interview and record review of building floor plans during tour on 11/2/11 and 11/3/11 with Staff B (Physical Plant Manager) revealed the locations of smoke barriers and smoke barrier doors.

Observation during tour on 11/3/11 at approximately 11:50 a.m. with Staff B and a representative from an outside agency revealed that the smoke barrier door at the smoke barrier separation located on the main floor at the Emergency Registration area is propped open by a door stop.

Interview during tour on 11/3/11 with Staff B confirmed the findings.

11-1, NFPA 99, HEALTH CARE FACILITIES
This chapter establishes minimum criteria for health care facility emergency preparedness management in the development of a program for effective disaster preparedness, mitigation, response, and recovery.

11-2, NFPA 99, HEALTH CARE FACILITIES
The purpose of this chapter is to provide those with the responsibility for disaster management planning in health care facilities with a framework to assess, mitigate, prepare for, respond to, and recover from, disasters. This chapter is intended to aid in meeting requirements for having an emergency preparedness management plan.

11-5.3.9, NFPA 99, HEALTH CARE FACILITIES
Drills: Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

3.1.3, NFPA 101, LIFE SAFETY CODE
Where terms are not defined in this chapter or within an occupancy chapter, they shall be defined using their ordinarily accepted meanings within the context in which they are used. Webster ' s Third New International Dictionary of the English Language, Unabridged, shall be a source for ordinarily accepted meaning.

Websters Dictionary, 3rd edition
Drill:
1. a: to fix something in the mind or habit pattern of by repetitive instruction... b: to impart or communicate by repetition... c: to train or exercise in military drill

Based on record review and interview revealed that the facility failed to provide documentation for two semi-annual disaster drills.

Findings include:

Record review during tour on 11/2/11 revealed that no documents were available in reference to disaster drills having been conducted.

Interview during tour on 11/2/11 and 11/3/11 with Staff B (Physical Plant Manager) revealed that two disaster drills were conducted within the past 12 months, however, documentation could not be provided at the time of survey.

Record review of documentation provided after tour via electronic mail on 11/14/11 revealed that the facility conducted a mass casualty disaster drill on 1/16/11. Documentation provided on 11/14/11 in a separate electronic mail revealed that the facility participated in an event which occurred on 3/21/11, however, the facility failed to provide written documentation regarding one of two semi-annual disaster drills that it was involved in.

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.

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

Based on observation and interview the facility failed to ensure that all required areas of the building are protected by an automatic, supervised sprinkler system.

Findings include:

Observation during tour on 11/2/11 at approximately 4:20 p.m. with Staff B (Physical Plant Manager) and a representative from an outside agency revealed that the Information Technology Department closet located on the first floor does not have sprinkler coverage provided inside the closet.

Interview during tour on 11/2/11 at the time of discovery confirmed the findings.

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

5-6.5.1.2 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.

Based on observation and interview the facility failed to ensure that the spray patterns of sprinkler heads are not obstructed.

Findings include:

Observation during tour on 11/3/11 at approximately 1:00 p.m. with Staff B (Physical Plant Manager) and a representative from an outside agency revealed that the spray pattern of a sprinkler head located in Rad. Tomo. room (107) is obstructed due to the deflector of the sprinkler head being approximately 1-1/2 inches from the ceiling, a ceiling mounted rail which has a depth of approximately 3-1/2 inches, and the distance between the sprinkler head and the rail approximately 8-1/2 inches.

Interview during tour on 11/3/11 with Staff B at the time of discovery confirmed the findings.

19.3.2.6, NFPA 101, LIFE SAFETY CODECooking 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.

4-3.1, NFPA 96, VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS
Openings shall be provided at the sides or at the top of the duct, whichever is more accessible, and at changes of direction. Openings shall be protected by approved access panels that comply with 4-3.4.4.

4-3.4.1, NFPA 96, VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS
On horizontal ducts, at least one 20 in. by 20 in. (508 mm by 508 mm) opening shall be provided for personnel entry. Horizontal ducting shall be secured sufficiently to allow for the weight of personnel entry into the duct. Where an opening of this size is not possible, openings large enough to permit thorough cleaning shall be provided at 12-ft (3.7-m) intervals.

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, Standard for 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.

9-2.2, NFPA 17, Standard for Dry Chemical Extinguishing Systems
If any deficiencies are found, appropriate corrective action shall be taken immediately.

9-2.3, NFPA 17, Standard for Dry Chemical Extinguishing Systems
Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions.

9-2.4, NFPA 17, Standard for Dry Chemical Extinguishing Systems
At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained until the next semiannual maintenance.

5-2.1, NFPA 17A, Standard for Wet Chemical Extinguishing Systems
Inspection shall be conducted on a monthly basis in accordance with the manufacturer ' s listed installation and maintenance manual or the 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) No obvious physical damage or condition exists that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps are intact and undamaged.
(h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.

5-2.2, NFPA 17A, Standard for Wet Chemical Extinguishing Systems
If any deficiencies are found, appropriate corrective action shall be taken immediately.

5-2.3, NFPA 17A, Standard for Wet Chemical Extinguishing Systems
Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions.

5-2.4, NFPA 17A, Standard for Wet Chemical Extinguishing Systems
At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained for the period between the semiannual maintenance inspections.

8-3.1, NFPA 96, VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS
Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.

Table 8-3.1 Exhaust System Inspection Schedule
Type or Volume of Cooking: Systems serving solid fuel cooking operations
Frequency: Monthly
Type or Volume of Cooking: Systems serving high-volume cooking operations such as 24-hour cooking, charbroiling or wok cooking
Frequency: Quarterly
Type or Volume of Cooking: Systems serving moderate-volume cooking operations
Frequency: Semiannually
Type or Volume of Cooking: Systems serving low-volume cooking operations, such as churches, day camps, seasonal businesses, or senior centers
Frequency: Annually

8-3.1.1, NFPA 96, VENTILATION CONTROL AND FIRE PROTECTION OF COMMERCIAL COOKING OPERATIONS
Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Section 8-3.

Based on record review, observation, and interview the facility failed to ensure that the kitchen hood system(s) are properly maintained.

Findings include:

Record review of kitchen hood inspection and cleaning reports during tour on 11/2/11 revealed that additional cleanout ports are needed.

Observation during tour on 11/2/11 between 3:10 p.m. and 3:20 p.m. with Staff B (Physical Plant Manager) and a representative from an outside agency revealed that the exterior portion of the hood above some cooking areas have visible grease build-up present.

Interview during tour on 11/2/11 with Staff B confirmed that the hood cleaning vendor has requested additional ports installed, confirmed that visible grease build-up is present, and revealed that the hood has not been inspected on a monthly basis by the facility.

4-3.1.1.1, NFPA 99, HEALTH CARE FACILITIES
Cylinder and Container Management: Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Based on observation and interview the facility failed to ensure that medical gas cylinders are properly secured and/or supported.

Findings include:

Observation during tour on 11/2/11 between 2:30 p.m. and 4:00 p.m. with Staff B (Physical Plant Manager) and a representative from an outside agency revealed that the medical gas cylinders located in the medical gas storage area and the area of the loading dock have multiple cylinders, consisting of at least 8 medical gas cylinders for each of the locations, secured with a single chain for each location.

Interview during tour on 11/2/11 at the time of discovery with Staff B confirmed the findings.

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.

8.3.6.1, 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.

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

Findings include:

Interview and record review of building floor plans during tour on 11/2/11 and 11/3/11 with Staff B (Physical Plant Manager) revealed the locations of smoke barriers.

Observation during tour on 11/2/11 at 3:30 p.m. and 11/3/11 at 4:00 p.m. with Staff B and a representative from an outside agency revealed that the following smoke barriers have unsealed penetrations:

1. Ground floor smoke barrier near the Material Manager Director Office.

2. Ground floor smoke barrier near Patient Financial Services.

3. Main floor smoke barrier at corridor in Occupational Health.

4. Main floor smoke barrier near PC116.

Interview during tour on 11/3/11 with Staff B confirmed the findings.