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NFPA 13
National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems, 2010 Edition

8.5.5 Obstructions to Sprinkler Discharge.
8.5.5.1* Performance Objective. Sprinklers shall be located so as to minimize obstructions to discharge as defined in 8.5.5.2 and 8.5.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard. (See Figure A.8.5.5.1.)
8.5.5.2* Obstructions to Sprinkler Discharge Pattern Development.
8.5.5.2.1 Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 8.5.5.2.
8.5.5.2.2 Sprinklers shall be positioned in accordance with the minimum distances and special requirements of Section 8.6 through Section 8.12 so that they are located sufficiently away from obstructions such as truss webs and chords, pipes, columns, and fixtures.
8.5.5.3* Obstructions That Prevent Sprinkler Discharge from Reaching the Hazard. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8.5.5.3.
8.5.5.3.1 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.
8.5.5.3.2 Sprinklers shall not be required under obstructions that are not fixed in place such as conference tables.
8.5.5.3.3* Sprinklers installed under open gratings shall be of the intermediate level/rack storage type or otherwise shielded from the discharge of overhead sprinklers.

8.6.4.1.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm) throughout the area of coverage of the sprinkler.

26.1* General
A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained by the property owner or their authorized representative in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system as required.

Findings include:

On 09/29/20, during a tour of the facility, the small emergency room closet had a pillow stored 15 inches (less than 18 inches) from the sprinkler deflector.

On 09/29/20, at the time of the finding, the Maintenance Director verbalized the pillow was stored too close to the sprinkler and should be moved.

Based on observation and interview, the facility failed to ensure corridor doors with self-closing devices were not obstructed from automatically closing.

Findings include:

On 09/29/20, the door to the Radiology Department check-in office was held open by a door chock. The door was constructed with a self-closing device and the chock prevented the door from operating as designed.

On 09/29/20, at the time of discovery, the Maintenance Director confirmed the door had self-closing hinges and should not have been held open.

National Fire Protection Association (NFPA) 70, National Electric Code, 2011 Edition
110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operations and maintenance of such equipment.
(A) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26 (A)(1), (A)(2), and (A)(3) or as required or permitted elsewhere in this Code.

(1) Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26 (A)(1) unless the requirements of 110.26 (A)(1)(a), (A)(1)(b), or (A)(1)(c) are met. Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed. (Nominal Voltage to Ground of 0 -150 = 3 feet).

(a) Dead-Front Assemblies. Working space shall not be required in the back or sides of assemblies, such as dead-front switch boards or motor control centers, where all connections and all renewable or adjustable parts, such as fuses or switches, are accessible from locations other than the back or sides. Where rear access is required to work on non-electrical parts on the back of enclosed equipment, a minimum horizontal working space of 762 mm (30 in.) shall be provided.
(b) Low Voltage. By special permission, smaller working spaces shall be permitted where all exposed live parts operate at not greater than 30 volts rms, 42 volts peak, or 60 volt dc.
(c) Existing Buildings. In existing buildings where electrical equipment is being replaced, Condition 2 working clearance shall be permitted between dead-front switch boards, panel boards, or monitor control centers located across the aisle from each other where conditions of maintenance and supervision ensure that written procedures have been adopted to prohibit equipment on both sides of the aisle from being open at the same time and qualified persons who are authorized will service the installation.

Article 400 - Flexible Cords and Cables
400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
1) As a substitute for the fixed wiring of a structure
2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
3) Where run through doorways, windows, or similar openings
4) Where attached to building surfaces
Exception to 4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
6) Where installed in raceways, except as otherwise permitted in the Code
7) Where subject to physical damage

Article 408.4 Field Identification Required
(A) Circuit Directory of Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include an approved degree of detail that allows each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard and at each switch or circuit breaker in a switchboard or switchgear. No circuit shall be described in a manner that depends on transient conditions of occupancy.

Based on observation and interview, the facility failed to ensure electrical wiring and equipment complied with the National Electric Code, National Fire Protection Association (NFPA) 70.

Findings include:

On 09/29/20, during a tour of the facility, the following was observed:

1) On 09/29/20, during a tour of the facility observation of electrical panelboards revealed the following panelboards had inaccurate schedule directories:
a) Panelboard D - Circuit breaker 17 was in the 'ON' position, however, there was no information for this breaker on the directory.
b) Panelboard F - Circuit breakers 2 and 4 and 21 and 23 were in the 'ON' position, however, the directory indicated these were spares.

On 09/29/20, the Maintenance Director confirmed the deficiencies at the time of discovery.

National Fire Protection Association (NFPA) 80, Standard for Fire Doors and Other Opening Protectives, 2010 Edition

19.4.9 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered.
19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected.
19.4.10 All documentation shall be maintained and made available for review by the AHJ.
19.4.11 Periodic inspections and testing of a combination fire/smoke damper shall also meet the inspection and testing requirements contained in Chapter 6 of NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives.
19.5 Maintenance.
19.5.1 Reports of changes in airflow or noise from the duct system shall be investigated to verify that they are not related to damper operation.
19.5.2* All exposed moving parts of the damper shall be dry lubricated as required by the manufacturer.
19.5.3 If the damper is not operable, repairs shall begin without delay.
19.5.4 Following any repairs, the damper shall be tested for operation in accordance with Section 19.4.

Based on document review and interview, the facility failed to provide evidence of fire and/or smoke damper testing.

Findings include:

The facility failed to provide evidence that fire and/or smoke dampers had been tested within the past four years.

On 09/29/20, the Maintenance Director confirmed the fire and/or smoke dampers had not been tested and inspected in the past four years.

NOTE: All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. Repairs to dampers are required to begin without delay. Dampers that are not functioning properly endanger the residents, staff and guests.

NFPA 99, Health Care Facilities Code, 2015 Edition
The requirements of Chapter 6 shall apply to the essential electrical system for the emergency power supply installation.

NFPA 110, Standard for Emergency and Standby Power System, 2013 Edition
5.6.5.6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.
5.6.5.6.1 The remote manual stop station shall be labeled.


Based on observation and interview, the facility failed to install a remote manual stop station outside of the housing for the essential electrical system (generator).

Findings include:

On 09/29/20, during a tour of the facility, observation of the essential electrical system (generator) revealed the facility lacked a manual stop station located in a remote location.

On 09/29/20, the Maintenance Director explained a remote annunciator scheduled to be installed included a remote shutoff. The Maintenance Director was unable to provide documentation ensuring the new annunciator included a remote shutoff function. The provided documentation indicated a stop switch, however, the installation location of the stop switch was not documented.

Based on observation and interview, the facility failed to properly store medical gas (oxygen) as required.

Findings include:

On 09/29/20, during a tour of the facility, the Central Supply room had a D cylinder oxygen tank stored unsecured on the floor . An employee verbalized owning the oxygen tank and stated it was empty.

On 09/29/20, the Maintenance Director acknowledged the oxygen tank should be secured at all times.