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Based on observations, staff interview, and/or documentation on August 7, 2018 at 10:30 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Two of three boilers/fire tubes had certificates that expired.
Titusville NC046648 also identified as Nat. Bd. #7518 expired 4/30/18 with two violations.
Kewanee NC255291 also identified as Nat. BD. #44057 expired 6/30/18.

2. Fourteen of eighteen pressure vessels had certificates that expired 6/30/18 and are identified as Nat. Bd. # as follows:
91630
11172
230411
15454M
86670
102739
89987
27217
245338
43140
341787
66535
5761
800201

3. Three of three heat exchangers had certificates that expired 6/30/18 and are identified as Nat. Bd. # as follows:
139852
51359
70481

Reference 2012 NFPA 101 19.7.6, 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, or other features shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.

This deficiency affected all smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on August 7, 2018 at 10:30 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The following doors had a dead bolt lock installed on the door requiring more than one releasing operation to open the door:
The corridor door to the offices in the TCU wing 1st floor were patient care rooms
Main conference room 1st floor
Main conference room restroom 1st floor
X-Ray rooms 1st floor
Ultra Sound room 1st floor
Reference 2012 NFPA 101 19.2.1.1, 7.2.1.10.2 - The releasing mechanism shall open the door leaf with not more than one releasing operation, unless otherwise specified in 7.2.1.5.10.3, 7.2.1.10.4, 7.2.1.5.10.6.

2. The door to emergency department medical director's office had a kick down on the door.
Reference 2012 NFPA 101 19.2.1.1, 7.1.9 Impediments to egress. Any device or alarm installed to restricted the improper use of a means of egress shall be designed and installed so that it cannot, even in case of failure, impede or prevent emergency use of such means of egress unless otherwise provided in 7.2.1.6 and chapters 18, 19, 22, 23.

3. The means of egress from the exit discharge to the ramp from the loading dock area was not protected. Facility did not have chains and/or guards installed to prevent someone form falling off the end of the loading dock.
Reference 2012 NFPA 101 19.2.1.1, 7.1.8 Guards. Guards in accordance with 7.2.2.4 shall be provided at the open sides of means of egress that exceed 30" (70 mm) above the floor or above the finished ground below.

4. Shared resident bathroom doors on 2nd, 3rd and 4th floor had locks that were installed that would prevent an individual from exiting the space. Reference NFPA 101 19.2.1, 7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied.

This deficiency affected the entire facility.
Failure to comply with minimum standards as referenced increases the risk of death due delayed egress from the facility.

Based on observations, staff interview, and/or documentation on August 7, 2018 at 10:30 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Facility at the time of the survey could not verify that the lights in the front canopy at the main entrance were connected to the emergency life safety circuit.
2. The emergency lighting in the stairwell located at the back of material management was not operational and/or not provided. The lights on the wall and ceiling outside the door were not operational.
3. At the exit discharge from the stairwell from the basement TCU area emergency egress lighting was not provided.
Reference 2012 NFPA 101 19.2.8 Illumination of means of egress. Means of egress shall be illuminated in accordance with Section 7.8.

This deficiency affected the emergency egress lighting.
Failure to comply with minimum standards as referenced increases the risk of death due to loss of power for lighting.

Based on observations, staff interview, and/or documentation on August 7, 2018 at 10:30 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The three doors to the "old smoking pit" did not have a sign reading "NO EXIT". The doors have glass panels and appeared to lead to the exterior of the building; therefore it could be mistaken for an exit.
Reference 2012 NFPA 101 Section 19.2.10.1 Means of egress shall have signs in accordance with section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4,
Reference 2012 NFPA 101 7.10.8.3.1 Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads NO EXIT.
Reference 2012 NFPA 101 Section 7.10.8.3.2 The NO EXIT sign shall have the word NO in letters 2" (51 mm) high, with a stroke width of 3/8" (9.5 mm), and the EXIT in letters 1" (25 mm) high, with the word EXIT below the word NO, unless such sign is an approved existing sign.

2. The exit directional light outside Day Surgery leading from the Administration exit was not operational.
Reference 2012 NFPA 101 Section 19.2.10.1 Means of egress shall have signs in accordance with section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4

3. Exit and directional signage is need in the basement material management area above the door in the break room/storage room that is accessible for the laundry area also.
Reference 2012 NFPA 101 Section 19.2.10.1 Means of egress shall have signs in accordance with section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4

4. Multiple exit direction signs are need in the large mechanical room in the basement in the material management area. The space is greater that 2500 square feet. Exit and directional sign will need to be installed when they can be seen and and not obstructed by equipment.
Reference 2012 NFPA 101 Section 19.2.10.1 Means of egress shall have signs in accordance with section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4

This deficiency affected egress.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on August 7, 2018 at 10:30 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The corridor door to the kitchen dry storage room was found wedged open preventing the door from closing. The room was greater than 50 square feet and is used for storage of combustible materials. Door was not equipped with a self-closing device as specified by NFPA 101: 19.3.2.1.3
2. The Hall bathroom on 4th floor at the time of the survey was used for storage. The room was greater than 50 square feet, and did not meet the requirement for hazardous storage as specified by NFPA 101, 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1.
3. The double door to the material management room were held open with hold open devices that would not release upon activation of the fire alarm.
4. The corridor door to the laundry room did not close and latch when checked. Room were greater than 100 square feet.
5. The bio hazard door located on 1st floor had the strike plate taped over prevent the door from closing. Room were greater than 50 square feet.
6. The clean utility and clean storage room located in the Day Surgery suite did not close and latches when checked. Rooms were greater than 50 square feet.

Actual NFPA Standard: NFPA 101, 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1.
19.3.2.1.1 An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with 19.3.5.9.
19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4.
19.3.2.1.3 The doors shall be self-closing or automatic-closing.
19.3.2.1.4 Doors in rated enclosures shall be permitted to have non-rated, factory- or field-applied protective plates extending not more than 48 in. (1220 mm) above the bottom of the door.
19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms (2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal
(242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard
This deficiency affected ** of ** smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on August 7, 2018 at 10:30 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. In the replacement air return for the kitchen hood the motorized damper in the air shaft was not operational and closed preventing replacement air from reaching the hood resulting in the hood not exhausting as designed. The facility was pulling the replacement air from the surrounding area and not from the outside as required. The facility will need to verify that a negative air balance (.02 inches water column) is not exceeded in the kitchen as specified by NFPA 96: 8.3.1
Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, or other features shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction.
2012 NFPA 101: 19.7.6; 4.6.12.1
NFPA 101: 19.3.2.5

This deficiency affected one smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on August 7, 2018 at 10:30 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The ABHR dispenser in operating room #5 was installed over the light switch.

Reference 2012 NFPA 101 19.3.2.6 Alcohol-Based Hand-Rub dispensers. (ABHR) dispensers shall be protected in accordance with 8.7.3.1
Reference 2012 NFPA 101 8.7.3.1 Dispensers are not installed within one inch of an ignition source.

This deficiency affected one smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on August 7, 2018 at 10:30 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The supervisory signal for the electronically supervised tamper alarm on the sprinkler control valve at the Fire Alarm Control Panel (FACP) in central security could be silenced permanently when the valve was in the closed position in the fire pump room. The signal was not silenced from central security but from the master alarm located in the maintenance shop.

Reference 2012 NFPA 101 Section 19.3.5.1, 9.7.2.1 Where supervised automatic sprinkler systems are required by another section of this code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, AND a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed at a location within the protected building that is constantly attended by qualified personnel.

This deficiency affected the sprinkler system. Failure to comply with minimum standards as referenced increases the risk death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on August 7, 2018 at 10:30 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Sprinkler certification from 7/12/18 showed one control valve in the outside hot box was deficient.

2. The sprinkler heads in the laundry room located in the basement area were not maintained clean and in good condition. There was an excessive amount of lint built up on the sprinkler pipes and heads.

Reference 2012 NFPA 101 19.3.5.4 The sprinkler system required by 19.3.5.1 or 19.3.5.3 shall be installed in accordance with 9.7 automatic sprinklers.
Reference 2012 NFPA 101 9.7. 5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25.
Reference 2011 NFPA 25 13.3.2.2 (5) The valve inspection shall verify that the valves are in the following condition. Free from external leaks.

2. The supervisory signal for the electronically supervised tamper alarm on the sprinkler control valve at the FACP in the central security office had an audible but not a visual signal when the valve was in the closed position in the fire pump room.

Reference 2012 NFPA 101 Section 19.3.5.4, 9.7.5, 2011 NFPA 25 5.1.1.1 This chapter shall provide the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. 5.1.1.2 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance. Table 5.1.1.2 Summary of Sprinkler System Inspection, Testing, and Maintenance, 5.2.5 Inspection Valve supervisory alarm devices Quarterly.

This deficiency affected the sprinkler system. Failure to comply with minimum standards as referenced increases the risk death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on August 7, 2018 at 10:30 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The corridor door to the kitchen dry storage room for the kitchen was not equipped with latching hardware.
2. The Hall bathroom on 4th floor at the time of the survey was used for storage and the door was not equipped with positive latching hardware.
3. The kitchen chemical storage closet corridor door was not equipped with latching hardware.
4. The second floor storage room at the birthing center was not positive latching.
5. The double doors to the break room/storage room in the basement of material management did not close and latch smoke tight. The inactive leaf of the two doors was found open with missing hardware preventing it from being latched into the frame in order for the second door to close and latch smoke tight.
6. The corridor doors to the Material Management storage room did not close and latch tight in its frame. The inactive leaf of the two doors was found open and not latched into the frame in order for the second door to close and latch smoke tight.

NFPA 101 19.3.6.3.

This deficiency affected two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on August 7, 2018 at 10:30 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

The following smoke barrier wall had failed or had improperly firestopped penetrations.

1. The barrier at x-ray on first floor at the communication closet had penetrations that were not properly sealed.
2. The barrier at the ED double doors on first floor across from scheduling and a med gas outlet had penetrations that were not properly sealed.
3. The barrier at the first floor north stair above the smoke door and to the right, had foam sealant that was approved for residential use.

2012 NFPA 101: 19.3.7.3 Any required smoke barrier shall be constructed in accordance with section 8.5 and shall have a minimum 1/2 hour fire resistance rating. 8.5, 4.5.8
2012 NFPA 101 Sections 19.3.7.3, 8.5, 8.5.6.2, 8.5.6.3, 8.5.6.5
2012 NFPA 101 Sections 19.1.1.1.3, 19.1.1.2, 4.1.1, 4.2.3, 4.5.8, 4.6.12.2, 4.6.12.4, 43.5.1.3
2012 NFPA 101 Sections 19.5.1, 9.1.2
2011 NFPA 70 Articles 300-21, 760-3(a), 820-26, 830-26

This deficiency affected several smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on August 7, 2018 at 10:30 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The electrical panel GHS located in the electrical room behind the engineering office was not equipped with a main breaker disconnect.

2012 NFPA 19.5.1.1, 9.1.1, 9.1.2, NFPA 70, National Electric Code

This deficiency affected the electrical system.
Failure to comply with minimum standards as referenced increases the risk of death due to electrical hazards.

Based on observations, staff interview, and/or documentation on August 7, 2018 at 10:30 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The smoke duct detector for HVAC unit #1 and unit #2 were not maintained clean and in good condition.
Reference 2012 NFPA 101: 19.5.2.1, 9.2.1, 2010 NFPA 90A: 6.4.4
2. The facility did not have emergency shutdown switches for HVAC Unit #1, HVAC Unit #2, Birthing Center, and the Day surgery unit. Reference 2012 NFPA 101: 19.5.2.1, 9.2.1, 2010 NFPA 90A: 6.2
3. The HVAC unit #1 did not shut down upon activation of the fire alarm by smoke duct detector on the return.
Reference NFPA 101: 19.5.2.1, 9.2.1, 2010 NFPA 90A: 6.4.3.1

This deficiency affected the entire facility.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on August 7, 2018 at 10:30 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. A soiled linen/trash container 55 gallons in size was being used in the Day Surgery suite and the container was left unattended. Reference 2012 NFPA 101, 19.7.5.7.1 Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity and shall meet all of the following requirements:
(1) The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2).
(2) A capacity of 32 gal (121 L) shall not be exceeded within any 64 ft2 (6 m2) area.
(3)*Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.
(4) Container size and density shall not be limited in hazardous areas.

This deficiency affected one smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on August 7, 2018 at 10:30 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. When testing the smoke evac system on 4th floor the facility could not verify that the return damper closed and that the fresh air intake was open. Reference 2012 NFPA 101: 19.7.7

This deficiency affected the entire facility.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on August 7, 2018 at 10:30 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. On the loading dock in the flammable gas storage cage there were three Type-E gas cylinders that were not properly secured. Reference 2012 NFPA 19.3.2.4, 99 11.6.2.3 (11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

This deficiency affected one smoke compartment exit egress.
Failure to comply with minimum standards as referenced increases the risk of death due mishandling of compressed gas.

Based on observations, staff interview, and/or documentation on August 7, 2018 at 10:30 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

The following smoke barrier wall had failed or had improperly firestopped penetrations.
1. The barrier above the door to the hyperbarics room on second floor had penetrations that were not properly sealed.

Reference 2012 NFPA 101 8.7.5 All occupancies containing hyperbaric facilities shall comply with NFPA 99, NFPA 101 Chapter 20.
2012 NFPA 101 Sections 19.3.7.3, 8.5, 8.5.6.2, 8.5.6.3, 8.5.6.5
2012 NFPA 101 Sections 19.1.1.1.3, 19.1.1.2, 4.1.1, 4.2.3, 4.5.8, 4.6.12.2, 4.6.12.4, 43.5.1.3
2012 NFPA 101 Sections 19.5.1, 9.1.2
2011 NFPA 70 Articles 300-21, 760-3(a), 820-26, 830-26

This deficiency affected several smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.