HospitalInspections.org

19.3.6.2.1, NFPA 101, LIFE SAFETY CODE
Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.

19.3.6.2.2, NFPA 101, LIFE SAFETY CODE
Corridor walls shall form a barrier to limit the transfer of smoke.

19.3.6.4, NFPA 101, LIFE SAFETY CODE
Transfer Grilles: Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in these walls or doors.

Based on observation and interview the facility failed to ensure that corridor walls are capable of resisting the passage of smoke.

Findings include:

Observation during tour on 5/17/11 with Staff B (Director of Support Services) revealed that the corridor wall has wood louver panels installed in a wall opening which is not designed to be smoke resistant in a corridor of the craft shop area where the corridor wall separates the corridor from a room containing HVAC (Heating, Ventilation, and Air Conditioning) equipment.

Interview during tour on 5/17/11 with Staff B confirmed the findings.

19.3.6.3.2, NFPA 101, LIFE SAFETY CODE
Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.

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.

Based on observation and interview the facility failed to ensure that doors equipped with self-closing devices function properly.

Findings include:

Observation during tour on 5/17/11 at approximately 11:40 a.m. with Staff B (Director of Support Services) revealed that the entry door to the business office equipped with a self-closing device installed has a door stop installed which prevents the self-closing device from operating and requires manual releasing to allow the door to close. Upon release of the door stop, the door did not close to a latched position.

Interview during tour on 5/17/11 with Staff B at the time of discovery confirmed the findings.

19.3.2.1, NFPA 101, LIFE SAFETY CODE
Hazardous Areas: Any hazardous areas shall be safe-guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 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) Soiled linen rooms
(6) Trash collection rooms
(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.

8.2.4.2, NFPA 101, LIFE SAFETY CODE
Smoke partitions shall extend from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces.
Exception: Smoke partitions shall be permitted to terminate at the underside of a monolithic or suspended ceiling system where the following conditions are met:
(a) The ceiling system forms a continuous membrane.
(b) A smoketight joint is provided between the top of the smoke partition and the bottom of the suspended ceiling.
(c) The space above the ceiling is not used as a plenum.

8.2.4.4.1, 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 smoke partitions shall be protected as follows:
(1) The space between the penetrating item and the smoke partition shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
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 partition, the sleeve shall be solidly set in the smoke partition, 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 limiting the transfer of smoke.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke partitions.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observation and interview the facility failed to ensure that hazardous areas are separated from other areas with smoke resisting walls and doors.

Findings include:

Observation during tour on 5/17/11 at approximately 10:35 a.m. with Staff B (Director of Support Services revealed that the generator room in the basement has a unsealed penetration of the interior side of the generator room and the exposed void space of the ceiling assembly on the opposite side of the wall is visible and will not prevent the migration of smoke from one side of the generator room to the other side.

Interview during tour on 5/17/11 with Staff B at the time of discovery confirmed the findings.

19.3.4.1, NFPA 101, LIFE SAFETY CODE
General: Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.4, NFPA 101, LIFE SAFETY CODE
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

2-3.5.1, NFPA 72, NATIONAL FIRE ALARM CODE
In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.

A-2-3.5.1, NFPA 72, NATIONAL FIRE ALARM CODE
Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.

7-5.2.2, NFPA 72, NATIONAL FIRE ALARM CODE
A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15)Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Based on record review, observation, and interview the facility failed to ensure that the fire alarm system is properly tested, maintained, and documented.

Findings include:

Record review of fire alarm vendor records during tour on 5/17/11 between 9:30 a.m. and 10:30 a.m. revealed that the vendor is not providing the following information on each inspection and testing record including the following as specified in Figure 7-5.2.2 of NFPA 72, National Fire Alarm Code:
1. MONITORING ENTITY
2. APPROVING AGENCY
3. TYPE TRANSMISSION
4. SERVICE FREQUENCY
5. CONTROL UNIT INFORMATION
6. SYSTEM POWER SUPPLIES (Primary and Secondary) including voltage and amps.
7. NOTIFICATION(S) MADE
8. Statement: "THIS TESTING WAS PERFORMED IN ACCORDANCE WITH APPLICABLE NFPA STANDARDS."

Observation during tour on 5/17/11 with Staff B (Director of Support Services) revealed that at least one smoke detector on the first floor in the area of "Quitting Time" corridor is within 12 inches of an HVAC (Heating, Ventilation, and Air Conditioning) vent.

Interview during tour on 5/17/11 with Staff B confirmed that information in regards to the fire alarm system is missing from the vendor report and that the smoke detector is less than 3 feet from an HVAC vent.

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 sprinkler protection is provided throughout.

Findings include:

Observation during tour on 5/17/11 between 11:30 a.m. and 2:15 p.m. with Staff B (Director of Support Services) revealed that the following areas do not have sprinkler heads present:

1. Kennedy Unit closet.

2. Washington Wing, room 4 closet.

3. Washington Wing, room 5 closet.

4. Lincoln Wing, shower room.

Interview during tour on 5/17/11 between 11:30 a.m. and 2:15 p.m. with Staff B 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.

5-13.11, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Electrical Equipment: Sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
Exception: Sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room.

19.1.1.4.1, NFPA 101, LIFE SAFETY CODE
...shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required...

19.1.1.4.2, NFPA 101, LIFE SAFETY CODE
...shall be protected by approved self-closing fire doors. (See also Section 8.2.)

8.2.3.2.1, NFPA 101, LIFE SAFETY CODE
Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

1-5.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.

1-6.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled fire doors shall be used.

2-3.1.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled door frames shall be used.

8.2.3.2.3.1, NFPA 101, LIFE SAFETY CODE
Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows:
(1) 2-hour fire barrier - 11/2-hour fire protection rating
(2) 1-hour fire barrier - 1-hour fire protection rating where used for vertical openings or exit enclosures, or 3/4-hour fire protection rating where used for other than vertical openings or exit enclosures, unless a lesser fire protection rating is specified by Chapter 7 or Chapters 11 through 42
(3) 1/2-hour fire barrier - 20-minute fire protection rating

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.

5-5.3.4, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Minimum Distance Between Sprinklers: A minimum distance shall be maintained between sprinklers to prevent operating sprinklers from wetting adjacent sprinklers and to prevent skipping of sprinklers. The minimum distance permitted between sprinklers shall comply with the value indicated in the section for each type or style of sprinkler.

5-6.3.4, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Minimum Distance Between Sprinklers: Sprinklers shall be spaced not less than 6 ft (1.8 m) on center.

Based on observation and interview the facility failed to ensure that maintenance of the sprinkler system is properly provided.

Findings include:

Observation during tour on 5/17/11 between 10:40 a.m. and 1:00 p.m. with Staff B (Director of Support Services) revealed the following:

1. Basement electrical room: The electrical room does not have sprinkler protection installed and the door assembly does not have a label demonstrating the fire rating and does not have a self-closing device installed.

2. Kennedy unit, kitchenette: The spray pattern for the sprinkler head in the kitchenette on Kennedy unit is obstructed by a soffit. The deflector of the sprinkler head is located approximately 4 inches from the ceiling. The side wall of the soffit projects from the ceiling approximately 13 inches. The distance (width) of the soffit measures approximately 4 feet, 6 inches.

3. Craft shop area, cleaning supply room: The cleaning supply room in the craft shop area has two sprinkler heads within approximately 4 feet of each other.

Interview during tour on 5/17/11 between 10:40 a.m. and 1:00 p.m. with Staff B confirmed the findings.

Based on observation and interview the facility failed to ensure that plug strips are used appropriately.

Findings include:

Observation during tour on 5/17/11 at approximately 11:00 a.m. with Staff B (Director of Support Services) revealed that a plug strip is connected to an additional plug strip which is connected to the power supply (electrical wall outlet).

Interview during tour on 5/17/11 with Staff B at the time of discovery confirmed the findings.

19.3.6.2.1, NFPA 101, LIFE SAFETY CODE
Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.

19.3.6.2.2, NFPA 101, LIFE SAFETY CODE
Corridor walls shall form a barrier to limit the transfer of smoke.

19.3.6.4, NFPA 101, LIFE SAFETY CODE
Transfer Grilles: Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in these walls or doors.

Based on observation and interview the facility failed to ensure that corridor walls are capable of resisting the passage of smoke.

Findings include:

Observation during tour on 5/17/11 with Staff B (Director of Support Services) revealed that the corridor wall has wood louver panels installed in a wall opening which is not designed to be smoke resistant in a corridor of the craft shop area where the corridor wall separates the corridor from a room containing HVAC (Heating, Ventilation, and Air Conditioning) equipment.

Interview during tour on 5/17/11 with Staff B confirmed the findings.

19.3.6.3.2, NFPA 101, LIFE SAFETY CODE
Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.

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.

Based on observation and interview the facility failed to ensure that doors equipped with self-closing devices function properly.

Findings include:

Observation during tour on 5/17/11 at approximately 11:40 a.m. with Staff B (Director of Support Services) revealed that the entry door to the business office equipped with a self-closing device installed has a door stop installed which prevents the self-closing device from operating and requires manual releasing to allow the door to close. Upon release of the door stop, the door did not close to a latched position.

Interview during tour on 5/17/11 with Staff B at the time of discovery confirmed the findings.

19.3.2.1, NFPA 101, LIFE SAFETY CODE
Hazardous Areas: Any hazardous areas shall be safe-guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. 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) Soiled linen rooms
(6) Trash collection rooms
(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.

8.2.4.2, NFPA 101, LIFE SAFETY CODE
Smoke partitions shall extend from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces.
Exception: Smoke partitions shall be permitted to terminate at the underside of a monolithic or suspended ceiling system where the following conditions are met:
(a) The ceiling system forms a continuous membrane.
(b) A smoketight joint is provided between the top of the smoke partition and the bottom of the suspended ceiling.
(c) The space above the ceiling is not used as a plenum.

8.2.4.4.1, 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 smoke partitions shall be protected as follows:
(1) The space between the penetrating item and the smoke partition shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
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 partition, the sleeve shall be solidly set in the smoke partition, 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 limiting the transfer of smoke.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke partitions.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observation and interview the facility failed to ensure that hazardous areas are separated from other areas with smoke resisting walls and doors.

Findings include:

Observation during tour on 5/17/11 at approximately 10:35 a.m. with Staff B (Director of Support Services revealed that the generator room in the basement has a unsealed penetration of the interior side of the generator room and the exposed void space of the ceiling assembly on the opposite side of the wall is visible and will not prevent the migration of smoke from one side of the generator room to the other side.

Interview during tour on 5/17/11 with Staff B at the time of discovery confirmed the findings.

19.3.4.1, NFPA 101, LIFE SAFETY CODE
General: Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.4, NFPA 101, LIFE SAFETY CODE
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

2-3.5.1, NFPA 72, NATIONAL FIRE ALARM CODE
In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.

A-2-3.5.1, NFPA 72, NATIONAL FIRE ALARM CODE
Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.

7-5.2.2, NFPA 72, NATIONAL FIRE ALARM CODE
A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15)Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Based on record review, observation, and interview the facility failed to ensure that the fire alarm system is properly tested, maintained, and documented.

Findings include:

Record review of fire alarm vendor records during tour on 5/17/11 between 9:30 a.m. and 10:30 a.m. revealed that the vendor is not providing the following information on each inspection and testing record including the following as specified in Figure 7-5.2.2 of NFPA 72, National Fire Alarm Code:
1. MONITORING ENTITY
2. APPROVING AGENCY
3. TYPE TRANSMISSION
4. SERVICE FREQUENCY
5. CONTROL UNIT INFORMATION
6. SYSTEM POWER SUPPLIES (Primary and Secondary) including voltage and amps.
7. NOTIFICATION(S) MADE
8. Statement: "THIS TESTING WAS PERFORMED IN ACCORDANCE WITH APPLICABLE NFPA STANDARDS."

Observation during tour on 5/17/11 with Staff B (Director of Support Services) revealed that at least one smoke detector on the first floor in the area of "Quitting Time" corridor is within 12 inches of an HVAC (Heating, Ventilation, and Air Conditioning) vent.

Interview during tour on 5/17/11 with Staff B confirmed that information in regards to the fire alarm system is missing from the vendor report and that the smoke detector is less than 3 feet from an HVAC vent.

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 sprinkler protection is provided throughout.

Findings include:

Observation during tour on 5/17/11 between 11:30 a.m. and 2:15 p.m. with Staff B (Director of Support Services) revealed that the following areas do not have sprinkler heads present:

1. Kennedy Unit closet.

2. Washington Wing, room 4 closet.

3. Washington Wing, room 5 closet.

4. Lincoln Wing, shower room.

Interview during tour on 5/17/11 between 11:30 a.m. and 2:15 p.m. with Staff B 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.

5-13.11, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Electrical Equipment: Sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
Exception: Sprinklers shall not be required where all of the following conditions are met:
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
(d) No combustible storage is permitted to be stored in the room.

19.1.1.4.1, NFPA 101, LIFE SAFETY CODE
...shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required...

19.1.1.4.2, NFPA 101, LIFE SAFETY CODE
...shall be protected by approved self-closing fire doors. (See also Section 8.2.)

8.2.3.2.1, NFPA 101, LIFE SAFETY CODE
Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

1-5.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.

1-6.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled fire doors shall be used.

2-3.1.1, NFPA 80, FIRE DOORS AND FIRE WINDOWS
Only labeled door frames shall be used.

8.2.3.2.3.1, NFPA 101, LIFE SAFETY CODE
Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows:
(1) 2-hour fire barrier - 11/2-hour fire protection rating
(2) 1-hour fire barrier - 1-hour fire protection rating where used for vertical openings or exit enclosures, or 3/4-hour fire protection rating where used for other than vertical openings or exit enclosures, unless a lesser fire protection rating is specified by Chapter 7 or Chapters 11 through 42
(3) 1/2-hour fire barrier - 20-minute fire protection rating

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.

5-5.3.4, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Minimum Distance Between Sprinklers: A minimum distance shall be maintained between sprinklers to prevent operating sprinklers from wetting adjacent sprinklers and to prevent skipping of sprinklers. The minimum distance permitted between sprinklers shall comply with the value indicated in the section for each type or style of sprinkler.

5-6.3.4, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Minimum Distance Between Sprinklers: Sprinklers shall be spaced not less than 6 ft (1.8 m) on center.

Based on observation and interview the facility failed to ensure that maintenance of the sprinkler system is properly provided.

Findings include:

Observation during tour on 5/17/11 between 10:40 a.m. and 1:00 p.m. with Staff B (Director of Support Services) revealed the following:

1. Basement electrical room: The electrical room does not have sprinkler protection installed and the door assembly does not have a label demonstrating the fire rating and does not have a self-closing device installed.

2. Kennedy unit, kitchenette: The spray pattern for the sprinkler head in the kitchenette on Kennedy unit is obstructed by a soffit. The deflector of the sprinkler head is located approximately 4 inches from the ceiling. The side wall of the soffit projects from the ceiling approximately 13 inches. The distance (width) of the soffit measures approximately 4 feet, 6 inches.

3. Craft shop area, cleaning supply room: The cleaning supply room in the craft shop area has two sprinkler heads within approximately 4 feet of each other.

Interview during tour on 5/17/11 between 10:40 a.m. and 1:00 p.m. with Staff B confirmed the findings.

Based on observation and interview the facility failed to ensure that plug strips are used appropriately.

Findings include:

Observation during tour on 5/17/11 at approximately 11:00 a.m. with Staff B (Director of Support Services) revealed that a plug strip is connected to an additional plug strip which is connected to the power supply (electrical wall outlet).

Interview during tour on 5/17/11 with Staff B at the time of discovery confirmed the findings.