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Based on observations, the facility failed to ensure there were no impediments to closing of the doors and that a dutch door had an astragal in accordance with NFPA 101, Sections 18.3.6.3.3 and 18.3.6.3.6. This deficiency has the potential to effect 2 of 5 smoke compartments on the main floor.

Findings include:

1. During an observation on 6/7/16 at 10:25 a.m., in the emergency room, the nourishment room door was blocked open with a wooden chock.¹

2. During an observation on 6/7/16 at 2:03 p.m., in the information billing office in the cardio area, there was a five eighths inch gap between the lower part of the dutch door and the upper part of the dutch door. There was no astragal between these sections of the dutch door.²

¹ NFPA 101, 2000 Edition, Section 18.3.6.3.3; Hold-open devices that release when the door is pushed or pulled shall be permitted. A.18.3.6.3.3 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.

² NFPA 101, 2000 Edition, Section 18.3.6.3.6; Dutch doors shall be permitted where they conform to 18.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel.

Based on observation the facility failed to ensure fire barriers separating building areas between which there are horizontal exits shall provide a separation that is continuous to ground in accordance with NFPA 101, 2000 Edition, Sections 7.2.4.3.1 and 8.2.3.2.4.2. This deficiency affects 3 of 5 main floor smoke compartments.

Findings include:

1. During an observation on 6/8/16 at 9:36 a.m., in a fire barrier just above the fire doors located in a service corridor just south of the MRI shell was an opening in a sleeve with data cables running through it. There was no sealant around these cables.¹ ²

2. During an observation on 6/8/16 at 9:45 a.m., in a fire barrier just above the fire doors located in the corridor running past imaging there was an opening in a sleeve that had data cables running through it. The red sealant had fallen out and was laying on a tile just under the sleeve.¹ ²

¹ NFPA 101, 2000 Edition, Section 7.2.4.3.1; Fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground. (See also 8.2.3.)
Exception: Where a fire barrier provides a horizontal exit in any story of a building, such fire barrier shall not be required on other stories, provided that the following criteria are met:
(a) The stories on which the fire barrier is omitted are separated from the story with the horizontal exit by construction having a fire resistance rating at least equal to that of the horizontal exit fire barrier.
(b) Vertical openings between the story with the horizontal exit and the open fire area story are enclosed with construction having a fire resistance rating at least equal to that of the horizontal exit fire barrier.
(c) All required exits, other than horizontal exits, discharge directly to the outside.

² NFPA 101, 2000 Edition, Section 8.2.3.2.4.2; 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.

Based on observation, the facility failed to maintain the horizontal exits barriers in accordance with NFPA 101, 2000 Edition, Section 7.2.4.3.1 and 8.2.3.2.4.2. This deficiency affects 2 of 5 main floor smoke compartments.

Findings include:

1. During an observation on 6/8/16 at 9:30 a.m., just past the entrance into the extended care facility from the hospital, there were a set of fire doors. Looking above these doors there was an opening in a sleeve that ran into the fire wall. There were some cables going into the sleeve without sealant around the cables.¹²

¹ NFPA 101, 2000 Edition, Section 7.2.4.3.1; Fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground. (See also 8.2.3.)
Exception: Where a fire barrier provides a horizontal exit in any story of a building, such fire barrier shall not be required on other stories, provided that the following criteria are met:
(a) The stories on which the fire barrier is omitted are separated from the story with the horizontal exit by construction having a fire resistance rating at least equal to that of the horizontal exit fire barrier.
(b) Vertical openings between the story with the horizontal exit and the open fire area story are enclosed with construction having a fire resistance rating at least equal to that of the horizontal exit fire barrier.
(c) All required exits, other than horizontal exits, discharge directly to the outside.

² NFPA 101, 2000 Edition, Section 8.2.3.2.4.2; 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.

Based on observation, record review and interview, the facility failed to ensure load voltage test were being completed in accordance with NFPA 72, 1999 Edition, Table 7.3.2 (6) (d) (3). This deficiency affects all smoke compartments.

Findings include:

Review of the fire alarm inspection report dated 1/5/16 did not indicate load voltage test were being completed semi-annually on lead-acid type batteries that were part of the fire alarm system.

In an interview on 6/8/16 at 8:50 a.m., staff member A said the alarm panel in the Fire Alarm Control Panel (FACP) in the sprinkler riser room was recently indicating a problem which turned out to be the need for the batteries to be replaced. The date on these batteries in the FACP was May 2016.

During the observation on 6/8/16 at 8:40 a.m., in the IT server room near the nurses station, the batteries in the FACP were examined and the battery dates were January 2012.¹


¹ NFPA 72 National Fire Alarm Code, 1999 Edition, Table 7.3.2 (6) (d) (3) requires sealed lead-acid type batteries to have a "Load Voltage Test" upon initial installation and then semi-annually thereafter.

Based on observation and interview, the facility failed to ensure where ducts were over four foot wide sprinkler protection was provided under them in accordance with NFPA 13, 1999 Edition, Section 5-7.5.3.2, and failed to ensure sprinklers were not obstructed in accordance with Section 5-6.5.1.2 and Table 5-6.5.1.2. These deficiencies affect 1 of 5 main floor and 1 of 2 second floor smoke compartments.

Findings include:

1. During an observation on 6/7/16 at 11:30 a.m., in the imaging area a light fixture was situated four inches from a sprinkler. The bottom of the light fixture was below the sprinkler. ¹

2. During an observation on 6/7/16 at 2:55 p.m., in the boiler room on the second floor, there was duct work that ran four and half feet off the floor and one above it. This duct work in both sections was over four and one half feet wide. There was no sprinkler underneath these sections that ran the width of the room.

In an interview on 6/7/16 at 2:55 p.m., staff member A, said these were make up air intake ducts.²

¹ NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-6.5.1.2; Sprinklers shall be arranged to comply with 5-5.5.2, Table 5-6.5.1.2, and Figure 5-6.5.1.2(a).
Exception No. 1: Sprinklers shall be permitted to be spaced on opposite sides of obstructions not exceeding 4 ft (1.2 m) in width provided the distance from the centerline of the obstruction to the sprinklers does not exceed one-half the allowable distance permitted between sprinklers.
Exception No. 2: Obstructions located against the wall and that are not over 30 in. (762 mm) in width shall be permitted to be protected in accordance with Figure 5-6.5.1.2(b).

Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP)
Distance from Sprinklers to Maximum Allowable
Side of Obstruction (A) Distance of Deflector
above Bottom of
Obstruction (in.) (B)
Less than 1 ft 0
1 ft to less than 1 ft 6 in. 2 1/2
1 ft 6 in. to less than 2 ft 3 1/2
2 ft to less than 2 ft 6 in. 5 1/2
2 ft 6 in. to less than 3 ft 7 1/2
3 ft to less than 3 ft 6 in. 9 1/2
3 ft 6 in. to less than 4 ft 12
4 ft to less than 4 ft 6 in. 14
4 ft 6 in. to less than 5 ft 16 1/2
5 ft and greater 18
For SI units, 1 in. = 25.4 mm; 1 ft = 0.3048 m.
Note: For (A) and (B), refer to Figure 5-6.5.1.2(a).

² NFPA 13, Standard for the Installation of Sprinklers, 1999 Edition, Section 5-7.5.3.2;
Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring cutting tables, and overhead doors.
Exception: Obstructions that are not fixed in place such as conference tables.

Based on observation, record review and interview, the facility failed to ensure the integrity of the automatic sprinkler system was continuously maintained, inspected and tested periodically in accordance with NFPA 25, 1998 Edition, Section 5.1.1. and NFPA 13, 1999 Edition, Section 5-6.6. The deficiency affects 1 of 2 basement smoke compartments.

Findings include:

1. During an observation in the basement physical therapy area on 6/7/16 at 4:20 p.m., an escutcheon ring had been pulled down.¹

2. During an observation in the basement laundry area on 6/7/16 at 4:30 p.m., there was a quarter size hole in the lay in ceiling near a light fixture.¹

3. During an observation in the basement storage room on 6/7/16 at 4:50 p.m., an upright sprinkler was 15 inches above a box stored on the top shelf.²


¹ NFPA 13 Standard for the Installation of Sprinkler Systems,1999 Edition, Section 5.1.1; 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
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.

² NFPA 13, 1999 Edition, Section 5-6.6 Clearance to Storage (Standard Pendent and Upright Spray Sprinklers).; The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
Exception: Where other standards specify greater minimums, they shall be followed.

Based on observation, record review and interview, the facility failed to ensure the integrity of the automatic sprinkler system was continuously maintained, inspected and tested periodically in accordance with NFPA 25, 1998 Edition, Sections 2-2.1.1 & 9-6.2.2 and NFPA 13, 1999 Edition, Section 5-1.1. These deficiencies affect 3 of 5 main floor smoke compartments.

Findings include:

1. During an observation on 6/7/16 at 9:15 a.m., a sprinkler in room 114 was covered with lint.¹

In an interview on 6/7/16 at 9:15 a.m., staff member A said a piece of the cleaning duster was stuck to the sprinkler.

2. During an observation on 6/7/16 at 11:19 a.m., in the imaging area a restroom just off the CAT scan area had an escutcheon ring that was hanging down away from the ceiling. Staff member A tried to push it back up but it would not move.²

3. During an observation on 6/7/16 at 11:44 a.m., in a janitor/dirty utility room near the nurses station, there were six openings in the lay in ceiling where conduits ran through this ceiling. These openings were not sealed around the conduits.²

In an interview on 6/7/16 at 11:44 a.m., staff member A said there were no sprinklers above the lay in ceiling.²

4. During an observation on 6/7/16 at 2:45 p.m., in the second floor janitor room was observed. There were three openings in the lay in ceiling. These openings were not sealed around the duct work and water pipe that ran into the ceiling.

In an interview on 6/7/16 at 2:45 p.m., staff member A, said the two openings with the foil covered ducts going into the ceiling were from the air inlets for the oxygen storage area below.²

5. During an observation on 6/7/16 at 3:00 p.m., in the second floor IT room was observed. The following deficiencies were noted:
a.) there was a whole ceiling tile removed,²
b.) two openings on the opposite side of the room where blue cables entered the drop in ceiling,² and
c.) two metal conduits ran into this ceiling with openings around each.²

6. During an observation on 6/7/16 at 3:30 p.m., in the IT closet across from the administration office, there were two openings into the lay in ceiling around a set of gray cables and black cables. There were openings around these cables that needed to be sealed where they ran into the lay in ceiling.²

7. During an observation on 6/7/16 at 3:35 p.m., in the public relations marketing office there was an opening around the escutcheon ring.²

8. Review of the testing for the backflow preventor indicated the last test was done 7/29/11.

In an interview on 6/7/16 at 7:20 a.m., staff member A said "I know the backflow preventor has not been done since 2011."³

¹ NFPA 25 Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems, 1998 Edition, Section 2-2.1; 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.
Exception No. 1*: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

² NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5.1.1; 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
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.

³ NFPA 25, 1998 Edition, Section 9-6.2.2; All backflow devices installed in fire protection water supply shall be tested annually at the designed flow rate of the fire protection system, including hose stream demands, if appropriate.
Exception: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be conducted at the maximum flow rate possible.

Based on observation and interview, the facility failed to develop laboratory emergency procedures for equipment shutdown procedures in accordance with NFPA 99, 1999 Edition, Section 10-2.1.3.1. This deficiency has the potential to affect 1 of 5 smoke compartments.

Findings include:

During an observation on 6/8/16 at 9:02 a.m., in the laboratory the hood system was observed. The system was plugged into the wall electrical outlet. There were electrical outlets inside the hood system. A cylindrical object on a base standing five inches from the floor of the inside of the hood had a glowing orange red heating element inside of it.

In an interview on 6/8/16 at 9:02 a.m., staff member C said they did not have any documented procedures for laboratory emergencies. They used the hospital emergency procedures. The device in the hood was an incinerator they used to sterilize loops. It burns off whatever is on the loop. To turn off the electricity to the hood "I guess you would just unplug it."

In an interview on 6/8/16 at 12 noon, staff member A, said they did not have any emergency procedures for the laboratory. They had evidence the personnel in the lab had done fire drills.¹

¹ NFPA 99 Standard for Health Care Facilities 1999 Edition, Section 10-2.1.3.1; Procedures for laboratory emergencies shall be developed. Such procedures shall include alarm actuation, evacuation, and equipment shutdown procedures, and provisions for control of emergencies that could occur in the laboratory, including specific detailed plans for control operations by an emergency control group within the organization or a public fire department.

Based on record review, the facility failed to have evidence that the generators were consistently inspected weekly in accordance with NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition, Section 6-4.1. This deficiency affects all smoke compartments.

Findings include:

Review of the documented weekly inspections of the generators failed to include the weeks of 1/1/16 to the 18th; 2/13/16 to the 2/22/16; 3/6/16 to 3/14/16; 4/1/16 to 4/11/16; and in May 5/9/16 to 5/22/16 was done as "Bi-Weekly" per the documentation. ¹

¹ NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition, Section 6-4.1; Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.

Based on observation and interview, the facility failed to use a power strip in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC. This deficiency affects 1 of 5 smoke compartments.

Findings include:

1. During an observation, in the cardio sleep room, on 6/7/16 at 2:12 p.m., there was a power strip that was not verified as a UL 1363.¹

In an interview on 6/7/16 at 2:12 p.m., staff member A, said that power strip was not St. Luke supplied.

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.

Based on observations, the facility failed to ensure there were no impediments to closing of the doors and that a dutch door had an astragal in accordance with NFPA 101, Sections 18.3.6.3.3 and 18.3.6.3.6. This deficiency has the potential to effect 2 of 5 smoke compartments on the main floor.

Findings include:

1. During an observation on 6/7/16 at 10:25 a.m., in the emergency room, the nourishment room door was blocked open with a wooden chock.¹

2. During an observation on 6/7/16 at 2:03 p.m., in the information billing office in the cardio area, there was a five eighths inch gap between the lower part of the dutch door and the upper part of the dutch door. There was no astragal between these sections of the dutch door.²

¹ NFPA 101, 2000 Edition, Section 18.3.6.3.3; Hold-open devices that release when the door is pushed or pulled shall be permitted. A.18.3.6.3.3 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.

² NFPA 101, 2000 Edition, Section 18.3.6.3.6; Dutch doors shall be permitted where they conform to 18.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel.

Based on observation the facility failed to ensure fire barriers separating building areas between which there are horizontal exits shall provide a separation that is continuous to ground in accordance with NFPA 101, 2000 Edition, Sections 7.2.4.3.1 and 8.2.3.2.4.2. This deficiency affects 3 of 5 main floor smoke compartments.

Findings include:

1. During an observation on 6/8/16 at 9:36 a.m., in a fire barrier just above the fire doors located in a service corridor just south of the MRI shell was an opening in a sleeve with data cables running through it. There was no sealant around these cables.¹ ²

2. During an observation on 6/8/16 at 9:45 a.m., in a fire barrier just above the fire doors located in the corridor running past imaging there was an opening in a sleeve that had data cables running through it. The red sealant had fallen out and was laying on a tile just under the sleeve.¹ ²

¹ NFPA 101, 2000 Edition, Section 7.2.4.3.1; Fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground. (See also 8.2.3.)
Exception: Where a fire barrier provides a horizontal exit in any story of a building, such fire barrier shall not be required on other stories, provided that the following criteria are met:
(a) The stories on which the fire barrier is omitted are separated from the story with the horizontal exit by construction having a fire resistance rating at least equal to that of the horizontal exit fire barrier.
(b) Vertical openings between the story with the horizontal exit and the open fire area story are enclosed with construction having a fire resistance rating at least equal to that of the horizontal exit fire barrier.
(c) All required exits, other than horizontal exits, discharge directly to the outside.

² NFPA 101, 2000 Edition, Section 8.2.3.2.4.2; 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.

Based on observation, the facility failed to maintain the horizontal exits barriers in accordance with NFPA 101, 2000 Edition, Section 7.2.4.3.1 and 8.2.3.2.4.2. This deficiency affects 2 of 5 main floor smoke compartments.

Findings include:

1. During an observation on 6/8/16 at 9:30 a.m., just past the entrance into the extended care facility from the hospital, there were a set of fire doors. Looking above these doors there was an opening in a sleeve that ran into the fire wall. There were some cables going into the sleeve without sealant around the cables.¹²

¹ NFPA 101, 2000 Edition, Section 7.2.4.3.1; Fire barriers separating building areas between which there are horizontal exits shall have a 2-hour fire resistance rating and shall provide a separation that is continuous to ground. (See also 8.2.3.)
Exception: Where a fire barrier provides a horizontal exit in any story of a building, such fire barrier shall not be required on other stories, provided that the following criteria are met:
(a) The stories on which the fire barrier is omitted are separated from the story with the horizontal exit by construction having a fire resistance rating at least equal to that of the horizontal exit fire barrier.
(b) Vertical openings between the story with the horizontal exit and the open fire area story are enclosed with construction having a fire resistance rating at least equal to that of the horizontal exit fire barrier.
(c) All required exits, other than horizontal exits, discharge directly to the outside.

² NFPA 101, 2000 Edition, Section 8.2.3.2.4.2; 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.

Based on observation, record review and interview, the facility failed to ensure load voltage test were being completed in accordance with NFPA 72, 1999 Edition, Table 7.3.2 (6) (d) (3). This deficiency affects all smoke compartments.

Findings include:

Review of the fire alarm inspection report dated 1/5/16 did not indicate load voltage test were being completed semi-annually on lead-acid type batteries that were part of the fire alarm system.

In an interview on 6/8/16 at 8:50 a.m., staff member A said the alarm panel in the Fire Alarm Control Panel (FACP) in the sprinkler riser room was recently indicating a problem which turned out to be the need for the batteries to be replaced. The date on these batteries in the FACP was May 2016.

During the observation on 6/8/16 at 8:40 a.m., in the IT server room near the nurses station, the batteries in the FACP were examined and the battery dates were January 2012.¹


¹ NFPA 72 National Fire Alarm Code, 1999 Edition, Table 7.3.2 (6) (d) (3) requires sealed lead-acid type batteries to have a "Load Voltage Test" upon initial installation and then semi-annually thereafter.

Based on observation and interview, the facility failed to ensure where ducts were over four foot wide sprinkler protection was provided under them in accordance with NFPA 13, 1999 Edition, Section 5-7.5.3.2, and failed to ensure sprinklers were not obstructed in accordance with Section 5-6.5.1.2 and Table 5-6.5.1.2. These deficiencies affect 1 of 5 main floor and 1 of 2 second floor smoke compartments.

Findings include:

1. During an observation on 6/7/16 at 11:30 a.m., in the imaging area a light fixture was situated four inches from a sprinkler. The bottom of the light fixture was below the sprinkler. ¹

2. During an observation on 6/7/16 at 2:55 p.m., in the boiler room on the second floor, there was duct work that ran four and half feet off the floor and one above it. This duct work in both sections was over four and one half feet wide. There was no sprinkler underneath these sections that ran the width of the room.

In an interview on 6/7/16 at 2:55 p.m., staff member A, said these were make up air intake ducts.²

¹ NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-6.5.1.2; Sprinklers shall be arranged to comply with 5-5.5.2, Table 5-6.5.1.2, and Figure 5-6.5.1.2(a).
Exception No. 1: Sprinklers shall be permitted to be spaced on opposite sides of obstructions not exceeding 4 ft (1.2 m) in width provided the distance from the centerline of the obstruction to the sprinklers does not exceed one-half the allowable distance permitted between sprinklers.
Exception No. 2: Obstructions located against the wall and that are not over 30 in. (762 mm) in width shall be permitted to be protected in accordance with Figure 5-6.5.1.2(b).

Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP)
Distance from Sprinklers to Maximum Allowable
Side of Obstruction (A) Distance of Deflector
above Bottom of
Obstruction (in.) (B)
Less than 1 ft 0
1 ft to less than 1 ft 6 in. 2 1/2
1 ft 6 in. to less than 2 ft 3 1/2
2 ft to less than 2 ft 6 in. 5 1/2
2 ft 6 in. to less than 3 ft 7 1/2
3 ft to less than 3 ft 6 in. 9 1/2
3 ft 6 in. to less than 4 ft 12
4 ft to less than 4 ft 6 in. 14
4 ft 6 in. to less than 5 ft 16 1/2
5 ft and greater 18
For SI units, 1 in. = 25.4 mm; 1 ft = 0.3048 m.
Note: For (A) and (B), refer to Figure 5-6.5.1.2(a).

² NFPA 13, Standard for the Installation of Sprinklers, 1999 Edition, Section 5-7.5.3.2;
Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring cutting tables, and overhead doors.
Exception: Obstructions that are not fixed in place such as conference tables.

Based on observation, record review and interview, the facility failed to ensure the integrity of the automatic sprinkler system was continuously maintained, inspected and tested periodically in accordance with NFPA 25, 1998 Edition, Section 5.1.1. and NFPA 13, 1999 Edition, Section 5-6.6. The deficiency affects 1 of 2 basement smoke compartments.

Findings include:

1. During an observation in the basement physical therapy area on 6/7/16 at 4:20 p.m., an escutcheon ring had been pulled down.¹

2. During an observation in the basement laundry area on 6/7/16 at 4:30 p.m., there was a quarter size hole in the lay in ceiling near a light fixture.¹

3. During an observation in the basement storage room on 6/7/16 at 4:50 p.m., an upright sprinkler was 15 inches above a box stored on the top shelf.²


¹ NFPA 13 Standard for the Installation of Sprinkler Systems,1999 Edition, Section 5.1.1; 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
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.

² NFPA 13, 1999 Edition, Section 5-6.6 Clearance to Storage (Standard Pendent and Upright Spray Sprinklers).; The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
Exception: Where other standards specify greater minimums, they shall be followed.

Based on observation, record review and interview, the facility failed to ensure the integrity of the automatic sprinkler system was continuously maintained, inspected and tested periodically in accordance with NFPA 25, 1998 Edition, Sections 2-2.1.1 & 9-6.2.2 and NFPA 13, 1999 Edition, Section 5-1.1. These deficiencies affect 3 of 5 main floor smoke compartments.

Findings include:

1. During an observation on 6/7/16 at 9:15 a.m., a sprinkler in room 114 was covered with lint.¹

In an interview on 6/7/16 at 9:15 a.m., staff member A said a piece of the cleaning duster was stuck to the sprinkler.

2. During an observation on 6/7/16 at 11:19 a.m., in the imaging area a restroom just off the CAT scan area had an escutcheon ring that was hanging down away from the ceiling. Staff member A tried to push it back up but it would not move.²

3. During an observation on 6/7/16 at 11:44 a.m., in a janitor/dirty utility room near the nurses station, there were six openings in the lay in ceiling where conduits ran through this ceiling. These openings were not sealed around the conduits.²

In an interview on 6/7/16 at 11:44 a.m., staff member A said there were no sprinklers above the lay in ceiling.²

4. During an observation on 6/7/16 at 2:45 p.m., in the second floor janitor room was observed. There were three openings in the lay in ceiling. These openings were not sealed around the duct work and water pipe that ran into the ceiling.

In an interview on 6/7/16 at 2:45 p.m., staff member A, said the two openings with the foil covered ducts going into the ceiling were from the air inlets for the oxygen storage area below.²

5. During an observation on 6/7/16 at 3:00 p.m., in the second floor IT room was observed. The following deficiencies were noted:
a.) there was a whole ceiling tile removed,²
b.) two openings on the opposite side of the room where blue cables entered the drop in ceiling,² and
c.) two metal conduits ran into this ceiling with openings around each.²

6. During an observation on 6/7/16 at 3:30 p.m., in the IT closet across from the administration office, there were two openings into the lay in ceiling around a set of gray cables and black cables. There were openings around these cables that needed to be sealed where they ran into the lay in ceiling.²

7. During an observation on 6/7/16 at 3:35 p.m., in the public relations marketing office there was an opening around the escutcheon ring.²

8. Review of the testing for the backflow preventor indicated the last test was done 7/29/11.

In an interview on 6/7/16 at 7:20 a.m., staff member A said "I know the backflow preventor has not been done since 2011."³

¹ NFPA 25 Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems, 1998 Edition, Section 2-2.1; 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.
Exception No. 1*: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

² NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5.1.1; 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
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.

³ NFPA 25, 1998 Edition, Section 9-6.2.2; All backflow devices installed in fire protection water supply shall be tested annually at the designed flow rate of the fire protection system, including hose stream demands, if appropriate.
Exception: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be conducted at the maximum flow rate possible.

Based on observation and interview, the facility failed to develop laboratory emergency procedures for equipment shutdown procedures in accordance with NFPA 99, 1999 Edition, Section 10-2.1.3.1. This deficiency has the potential to affect 1 of 5 smoke compartments.

Findings include:

During an observation on 6/8/16 at 9:02 a.m., in the laboratory the hood system was observed. The system was plugged into the wall electrical outlet. There were electrical outlets inside the hood system. A cylindrical object on a base standing five inches from the floor of the inside of the hood had a glowing orange red heating element inside of it.

In an interview on 6/8/16 at 9:02 a.m., staff member C said they did not have any documented procedures for laboratory emergencies. They used the hospital emergency procedures. The device in the hood was an incinerator they used to sterilize loops. It burns off whatever is on the loop. To turn off the electricity to the hood "I guess you would just unplug it."

In an interview on 6/8/16 at 12 noon, staff member A, said they did not have any emergency procedures for the laboratory. They had evidence the personnel in the lab had done fire drills.¹

¹ NFPA 99 Standard for Health Care Facilities 1999 Edition, Section 10-2.1.3.1; Procedures for laboratory emergencies shall be developed. Such procedures shall include alarm actuation, evacuation, and equipment shutdown procedures, and provisions for control of emergencies that could occur in the laboratory, including specific detailed plans for control operations by an emergency control group within the organization or a public fire department.

Based on record review, the facility failed to have evidence that the generators were consistently inspected weekly in accordance with NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition, Section 6-4.1. This deficiency affects all smoke compartments.

Findings include:

Review of the documented weekly inspections of the generators failed to include the weeks of 1/1/16 to the 18th; 2/13/16 to the 2/22/16; 3/6/16 to 3/14/16; 4/1/16 to 4/11/16; and in May 5/9/16 to 5/22/16 was done as "Bi-Weekly" per the documentation. ¹

¹ NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition, Section 6-4.1; Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.

Based on observation and interview, the facility failed to use a power strip in accordance with the Centers for Medicare and Medicaid Services (CMS) Policy S&C-14-46-LSC. This deficiency affects 1 of 5 smoke compartments.

Findings include:

1. During an observation, in the cardio sleep room, on 6/7/16 at 2:12 p.m., there was a power strip that was not verified as a UL 1363.¹

In an interview on 6/7/16 at 2:12 p.m., staff member A, said that power strip was not St. Luke supplied.

¹ CMS Survey & Certification Policy S&C-14-46-LSC Categorical Waiver for Power Strips Use in Patient Care Areas, Issued 9/26/14.