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Based on observations and confirmed by staff, the facility failed to ensure compliance with chapter 19. Section 19.3.6.1 states corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. Section 19.3.6.3.1 states doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke.
Section 19.3.6.2.3 states fixed fire window assemblies in accordance with 8.2.3.2.2 shall be permitted in corridor walls.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 8/7/12 & 8/8/12, the following items were observed regarding corridor walls:

1) The radiology area "Pod 1" has numerous rooms (#'s 5; 6; 7; 8; 9; 10 and 11) open to the corridor. In addition, there are pass through windows in each of the x-ray rooms opening onto the corridor.
2) There are five (5) holding rooms open to the corridor in the radiology area.
3) The radiology waiting room is open to the corridor.
4) The Interventional Radiology area has four (4) holding rooms open to the corridor.
5) The Urology office is open to the corridor.
6) The 7th floor Med-room & staff Breakroom are equipped with tempered glass walls & doors. This smoke compartment is "partially sprinklered".
7) The 6th floor Med-room is equipped with tempered glass walls & door. This smoke compartment is "partially sprinklered".

Note: The plans provided by the hospital identified the above area's as utilizing corridors in lieu of suite designations. In addition, smoke detectors are not located in any of the above mentioned open area's and are spaced randomly throughout the main hospital corridors.

This was observed by hospital administration staff while touring the facility.

Based on observations and confirmed by staff, the facility failed to ensure compliance with chapter 19. Section 19.3.6.3 requires corridor doors other than vertical openings, exits or hazards areas to be 1-3/4" thick, solid-bonded core wood or of construction that resists fire for at least 20 minutes and shall be constructed to resist the passage of smoke. There shall be no impediment to closing the door, only approved hold open devices may be used.

THE FINDINGS INCLUDE:

- During the morning hours of 8/8/12 while touring the facility, it was observed that the doors to the patient bedrooms in the Medical Intensive Care Unit (MICU) do not latch. The doors are a sliding type that do not have latching devices.

This was observed by the Director of Facilities during the facility tour.

Based on observations and confirmed by staff, the facility failed to ensure that corridors doors are designed as required. Section 19.3.6.3.8 states fixed fire window assemblies in accordance with 8.2.3.2.2 shall be permitted in corridor doors.

THE FINDINGS INCLUDE:

- During the morning hours of 8/8/12 while touring the facility, it was observed that the doors & walls to the partially-sprinklered suite "G" and partially sprinklered seventh and sixth floor levels west and center wings are equipped with non-rated tempered glass.

This was observed by hospital administration staff while touring the facility.

Based on observations and confirmed by staff, the facility failed to ensure that smoke barrier doors are held open by approved devices. Section 19.2.2.2.6 states any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.
Section 7.2.1.8.2 states that in any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.
Section 2-10.6.2 states smoke detectors that are used exclusively for smoke door release service shall be located and spaced as required by 2-10.6. Section 2-10.6.5.1.1 states if the depth of wall section above the door is 24 in. (610 mm) or less, one ceiling-mounted detector shall be required on one side of the doorway only located at a maximum of five feet (5') from the door. Section 2-10.6.5.1.1 states if the wall section above the door is greater than twenty four inches (24") then a ceiling mounted detector is to be mounted on each side of the door way.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 8/7/12 & 8/8/12, it was observed that numerous smoke barrier doors are held open by magnetic devices. Upon further observations, it was noted that smoke detectors are not properly provided for the release of these smoke barrier doors. These include but are not limited to the following locations:

1) The double doors identified as 2-1168E leading into the Radiology area.
2) The double doors adjacent to room 7E09.
3) The 6th floor double doors identified as 6-023.
4) The door identified as 6E09.
5) The double doors identified as 5-024.
6) In the Clinic areas on the 5th, 6th, and 7th floor's there are doors located in two-hour fire rated walls being held open with devices that release upon activation of the fire alarm.

Note: The corridors are randomly equipped with smoke detectors mandating the requirement of smokes for individual door release.

This was observed by hospital administration staff while touring the facility.

Based on observations, plan review, and confirmed by staff, the facility failed to provide smoke barrier walls with a 1-hour fire rating assembly.

THE FINDINGS INCLUDE:

- During the morning hours of 8/8/12 while touring the facility, it was observed that the smoke barrier walls located by the Surgical Intensive Care Unit (SICU) are identified as 30-minute walls on the building floor plans. This was also substantiated during the building tour as it was observed that tempered glass (non-rated) transoms are used in various locations in the designated smoke walls.
Note: These walls are required smoke barrier walls in order to keep travel distances and smoke compartment sizes within the allowable parameters.

This was observed by hospital administration staff while touring the facility.

Based on observations and confirmed by staff, the facility failed to assure that hazardous area's are constructed/separated as required. Section 18.3.2.1 states any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated. Table 18.3.2.1 requires mechanical spaces to be enclosed with a minimum 1-hour fire rating wall assembly.

THE FINDING INCLUDE:

- During the morning hours of 8/8/12 while touring the facility, it was observed that the main mechanical room is not enclosed with the proper 1-hour rated assembly. The door leading into the mechanical space has a tempered glass transom panel which is non-rated.

This was observed by hospital administration staff while touring the facility.

Based on observations and confirmed by staff, the facility failed to ensure that stairwells are maintained as required:

THE FINDINGS INCLUDE:

- During the afternoon hours of 8/7/12, the following items were observed regarding stairwell doors:

1) Stair door #10 on the 4th floor level does not latch when fully closed.
2) Stair door #3 on the 2nd floor level does not latch when fully closed.
3) Stair door #5 on the 2nd floor level does not latch when fully closed.

Note: The hospital staff had the maintenance department immediately adjust these doors when brought to their attention.

This was observed by hospital administration staff while touring the facility.

Based on observations and confirmed by staff, the facility failed to ensure that maximum travel distances to exit egress locations are not exceeded. Section 18.2.6.2.1 states the travel distance between any room door required as an exit access and an exit shall not exceed 150 ft (45 m).
Section 18.2.6.2.2 states the travel distance between any point in a room and an exit shall not exceed 200 ft (60 m).
Section 18.2.6.2.4 states the travel distance between any point in a suite of sleeping rooms as permitted by 18.2.5 and an exit access door of that suite shall not exceed 100 ft (30 m) and shall meet the requirements of 18.2.6.2.2.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 8/8/12 while touring the facility, it was observed that the distances from the following locations were in excess of 200'.

1) The overall distance from the corner office in the anesthesia area is 260' to the exit by stair #2-0771 and 220' to the exit from the "J" corridor.

2) The overall distance from patient room #2E21 in the Surgical Intensive Care Unit (SICU) is 241' to exit adjacent to stair #13 and 218' to the 2-hour wall in the "J" corridor.

Note: The facility did have floor plans designating 2-hour wall locations for travel distances. However, when the walls were checked for integrity, it was observed that the walls were not 2-hour rated as noted.

This was observed by hospital administration staff while touring the facility.

Based on observations and confirmed by staff, the facility failed to ensure that maximum travel distances to exit egress locations are not exceeded. Section 19.2.6.2.1 states the travel distance between any room door required as an exit access and an exit shall not exceed 100 ft (30 m).
Exception: The maximum travel distance shall be permitted to be increased by 50 ft (15 m) in buildings protected throughout by an approved, supervised automatic sprinkler system.
Section 19.2.6.2.2 states the travel distance between any point in a room and an exit shall not exceed 150 ft (45 m).
Exception: The maximum travel distance shall be permitted to be increased by 50 ft (15 m) in buildings protected throughout by an approved, supervised automatic sprinkler system.
Section 19.2.6.2.4 states the travel distance between any point in a suite of sleeping rooms as permitted by 19.2.5 and an exit access door of that suite shall not exceed 100 ft (30 m) and shall meet the requirements of 19.2.6.2.2.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 8/8/12 while touring the facility, it was observed that the distances from the partially-sprinklered operating suites are all in excess of 100'. The travel distance is 175' to stair #2-0771 and 220' to the 2-hour rated "J" corridor exit door.

Note: The facility did have floor plans designating 2-hour wall locations for travel distances. However, when the walls were checked for integrity, it was observed that the walls were not 2-hour rated as noted.

This was observed by hospital administration staff while touring the facility.

Based on observations and confirmed by staff, horizontal exits are not maintained as required. Section 7.2.4.3.1 states 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.

THE FINDINGS INCLUDE:

- During the morning hours of 8/8/12 while touring the 2nd floor level Emergency Department (E.D.) Suite, the 2-hour fire rated barrier, separating the E.D. from the area outside the E.D., utilized by building tenants, was not properly constructed. H.V.A.C. ducts penetrating the barrier wall are not all equipped fire damper access doors.
This was noted from Exam Room #12 through Exam Room #14. The wall separates Exam Room #12 to a women's bathroom, Exam Room #14 to a corridor serving the Phlebotomy lab.
Without the H.V.A.C. access doors, verifying and servicing fire dampers is not possible.
This was observed by the Director of Facilities (D.O.F.) during the facility tour. The D.O.F said that reconstruction contractor's within the facility failed to identify these ducts and a facility vendor would be immediately called in to identify and remediate any fire damper deficiencies.

Based on observations and confirmed by staff, horizontal exits are not maintained as required. Section 7.2.4.3.1 states 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. Section 8.2.3.2.3.1 requires every opening in a fire barrier to 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 in a 2-hour fire barrier are required to have a 1-1/2-hour fire protection rating. NFPA 80, Section 2.1.4.1 requires self-closing doors to swing easily and freely and to be equipped with a closing device to cause the door to close and latch each time it is opened. Section 2.4.1.4 requires all closing mechanisms to be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

THE FINDINGS INCLUDE:

I. During the morning & afternoon hours of 8/6/12 and 8/7/12 while touring the facility, the following items were observed regarding 2-hour fire rated barrier doors. These include but are not limited to the following locations:

1) The door to the data closet identified as # 2J4.1 has a 20-minute fire rating label.
2) The door to the radiology conference room has a 20-minute fire rating label.
3) One of the double doors located by the central elevator currently drags on the floor and does not self close & latch.
4) Door # 2J-13.1 does not latch.
5) Door # 16 does not latch.
6) The 7th floor door # 7-023 does not latch.
7) Door # 6M-13 drags on the floor and does not self close & latch.
8) The 5th floor door # 5H 3.3 does not latch.
9) The 5th floor door # 5G-01 has a 3/8" gap between the door leaves.
10) The 7th floor door adjacent to # 7W01 does not latch.
11) The 7th floor door adjacent to # 7C01 does not latch.
12) The 7th floor door adjacent to # 7C38 does not latch.
13) The 6th floor door adjacent to # 6W36 does not latch.
14) The 5th floor door adjacent to # 5W36 had the closer arm disconnected.

II. During the morning & afternoon hours of 8/6/12 and 8/7/12 while touring the facility, the following items were observed regarding 2-hour fire rated barrier walls. These include but are not limited to the following locations:

The Emergency Department's 2-hour fire rated barrier wall between the "Family Consult" Room and patient sitting area has a 1" diameter void below the in-lay ceiling tiles. The void is in place to allow a wire cable to release via a fusible link in the event that the link releases.

These were observed by hospital administration staff while touring the facility. Hospital staff said that they were aware of the many door "problems" and that purchase orders were in place to replace and /or retro-fit door latching hardware.

Based on record review and confirmed by staff, it was revealed that the facility failed to ensure the fire alarm system is maintained as required. NFPA #72 (National Fire Alarm Code) section 7-1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request. Section 2-3.5.1 states smoke detectors shall not located in a direct airflow nor closer than three feet (3') from an air supply diffuser or return air opening.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 8/6/12 and 8/7/12 while touring the facility, the following items were observed regarding the maintenance & placement of smoke detectors. These include but not limited to the following locations:

1) The smoke detector in the operating-room storage room currently has a protective dust cap installed preventing the device from functioning as designed.
2) The smoke detector in the electrical closet 5G-09 currently has a protective dust cap installed preventing the device from functioning as designed.
3) Smoke detectors located at less than 3' from an air diffuser are as follows: 6th & 7th floor elevator #14/17 lobby's; by room # 7E05; by room # 6E26; by room 5H39 and by room 5-651.

This was observed by hospital administration staff while touring the facility.

Based on record review and confirmed by staff interview, the facility failed to ensure that the fire alarm system is maintained and tested as required. LSC Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition. NFPA 72, Section 7.3.2.1 requires smoke detector sensitivity to be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

THE FINDINGS INCLUDE:

- Records reviewed on the morning of 8/8/12 revealed that there was no documentation available substantiating that the sensitivity of smoke detectors has been checked as required in the Clinic areas.



This was observed by hospital administration staff while touring the facility.

Based on observations and confirmed by staff, the facility failed to ensure that non-sprinklered electrical rooms/closets are properly separated. NFPA 13 section 5-13.11 states that sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
The exception states 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.
NFPA 101 Section 8.2.3.2.3.1 requires openings in 2-hour rated fire barriers to be protected by doors having at least a 90 minute fire protection rating.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 8/6/12 and 8/7/12 while touring the facility, it was observed that not all electrical closets are designed as required. These include but are not limited to the following locations:

1) The non-sprinklered electrical room # 7K-40 is equipped with a 20-minute rated door.
2) The non-sprinklered electrical room # 7K-18 is equipped with a 20-minute rated door.

This was observed by hospital administration staff while touring the facility.

Based on observations and confirmed by staff, the facility failed to ensure that all sprinkler control valves are properly supervised. Section 9.7.2.1 states 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 Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 8/8/12 it was observed that not all sprinkler valves are electronically supervised as required. These include but not limited to the following valves:

1) There are two Post Indicator Valves (PIV) that are not electronically supervised. These PIV's control the main water supply to the automatic sprinkler system for the facility. There is one located outside at the loading dock and the other is located outside of the Emergency Department.
Note: The wrench attached to the valve is currently padlocked.

2) The loading dock anti-freeze loop has three (3) sprinkler valves which are not supervised. These include one (1) outside stem and yolk (OS&Y) and two (2) butterfly type valves.

This was observed by the Director of Facilities during the facility tour.

Based on record review and observation, the facility failed to ensure that the automatic sprinkler system is maintained, tested and inspected as required by NFPA #25. Section 1.8 requires records of inspections, tests and maintenance of the system and components be kept and made available to the authority having jurisdiction. Section 1.8.1 requires records to indicate the procedure performed, the organization that performed the work, the results, and the date. Section 2.3.2 requires pressure gauges to be replaced or tested every 5 years. Section 2.2.1.1 requires sprinklers to be free of corrosion, foreign material, paint, and physical damage. Any sprinkler shall be replaced that is painted, corroded damaged, or loaded.

THE FINDINGS INCLUDE:

During the morning & afternoon hours of 8/8/12 while touring the hospital the following was observed:

1) The sprinkler pressure gauges at the following locations are dated 1977 and 1978: Standpipe #2, standpipe #4, standpipe # 5, standpipe #6, the main fire booster pump and main fire pump.

2) The recessed sprinkler heads in the main lobby and cafeteria area been painted.

This was observed by the Director of Facilities during the facility tour.

Based on observations, record review and confirmed by staff, the facility failed to ensure compliance with NFPA 90A. Section 3.3.1.1 requires approved fire dampers to be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more. Section 3.3.1.2 requires approved fire dampers to be provided in all air transfer openings in partitions that are required to have a fire resistance rating and in which other openings are required to be protected.
Section 2.3.4.1 requires a service opening to be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device. Section 2.3.4.2 requires service openings to be identified with letters having a minimum height of 1/2 in. to indicate the location of the fire protection device(s) within. Section 2.3.8 requires fire dampers to be installed in conformance with the conditions of their listings. Section 3.4.6.2 requires fire dampers, including their sleeves; smoke dampers; and ceiling dampers to be installed in accordance with the conditions of their listings and the manufacturer ' s installation instructions.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 8/6/12 and 8/7/12 while touring the facility, the following ducts were observed penetrating 2-hour fire walls. The ducts noted below have no access panels to determine if fire dampers are in fact installed and/or maintained as required. These locations include but are not limited to the following locations:

1) Above the Trump connector door there is a 16" x 12" duct.
2) Above door #2-003 there are two (2) 10" x 10" ducts.
3) Above the radiology conference room there is a 16" x 12" duct.
4) Above the Post Anesthesia Care Unit (PACU) nurse's locker room wall there is a 12" x 10" duct.
5) Above the cross corridor wall by stair #10 there is a 24" x 12" duct.

This was observed by hospital administration staff while touring the facility.

Based on observations during the building tour and confirmed by staff, the facility failed to ensure compliance with the restrictions of portable space heating devices. Section 9.7.8 states portable space-heating devices shall be prohibited in all health care occupancies.

THE FINDING INCLUDE:

- During the morning & afternoon hours of 8/6/12 and 8/7/12 while touring the facility, portable space heaters were observed but not limited to the following locations:.

1) The office within the facility's management department.
2) The liver transplant office room #4E44.
3) The nursing office identified as 6K-06.
4) The office identified as 5G-10.5.

Note: These were all immediately removed when brought to the hospital staff's attention.

Based on observations and confirmed by staff, the facility failed to ensure proper separation from the adjacent dialysis unit by a 1-hour fire separation. Section 6.1.14.2 states where a mixed occupancy classification occurs, the means of egress facilities, construction, protection, and other safeguards shall comply with the most restrictive life safety requirements of the occupancies involved. Section 21.1.2.1 states sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
(1) They are not intended to serve ambulatory health care occupants for purposes of treatment or customary access by patients incapable of self-preservation.
(2) They are separated from areas of ambulatory health care occupancies by construction having a fire resistance rating of not less than 1 hour.

THE FINDINGS INCLUDE:

1) During the morning hours of 8/9/12 while touring the facility, it was observed that the wall above the dialysis door has a 16" x 3' and a 2' x 3' piece of drywall missing.
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Based on observations and confirmed by staff, the facility failed to ensure that stairwells are properly maintained as required. Section 8.2.5.2 states openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier. Section
8.2.5.4 states the fire resistance rating for the enclosure of floor openings shall be not less than as follows (see 7.1.3.2.1 for enclosure of exits):
(3) Existing enclosures in existing buildings - 1/2-hour fire barriers

THE FINDINGS INCLUDE:

2) During the morning hours of 8/9/12 while touring the facility, it was observed that the front stairwell (required) is lacking self closing devices on three of the top landing level doors.
3) During the morning hours of 8/9/12 while touring the facility, it was observed that the top door of the rear stairwell (required) does not latch when in the closed position.
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Based on observations and confirmed by staff, the facility failed to ensure that sprinkler heads are installed as required. NFPA 13 section 5-6.4.1.1 states 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).

THE FINDINGS INCLUDE:

4) During the morning hours of 8/9/12 while touring the facility, it was observed that the sprinklered electric room is missing approximately twelve (12) ceiling tiles. The sprinkler heads are currently located 4' below the deck above.
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These items were observed by hospital administration staff while touring the facility.

Based on observations, record review, and confirmed by staff, the facility failed to ensure that sprinkler systems are maintained as required. NFPA 25 section 2-3.3 states waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly. Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector's test connection which simulates activation of a sprinkler head. Section 2-3.2 states gauges on sprinkler systems shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. Section 2.2.1.1 requires sprinklers to be free of corrosion, foreign material, paint, and physical damage. Any sprinkler shall be replaced that is painted, corroded damaged, or loaded.

THE FINDINGS INCLUDE:

- During the morning hours of 8/9/12 the following items were observed regarding the sprinkler system:

1) The sprinkler system is only inspected/tested one time per calendar year.
2) The sprinkler gauges are dated 1989 & 2003.
3) The recessed sprinkler heads in the atrium area have all been recently painted.
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Based on observations and confirmed by staff, the facility failed to ensure that exit stairs are maintained as required. Section 7.2.2.5.3 states there shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.

THE FINDINGS INCLUDE:

4) During the morning hours of 8/9/12 a total of five (5) large trash carts were observed as being stored in the rear stairwell.
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Based on record review and confirmed by staff, it was revealed that the facility failed to ensure the fire alarm system is maintained as required. NFPA #72 (National Fire Alarm Code) section 7-1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

THE FINDINGS INCLUDE:

5) During the morning hours of 8/9/12 upon entering the building, the main fire alarm panel was observed as being in the "trouble" mode. When the building maintenance director was asked about this condition, he acknowledged that he was aware of the trouble situation. It was further stated that the building was under renovations (mainly cosmetics) and that the repair would not be made until all the work was completed. The work had been going on for approximately a couple of weeks and was slated for approximately two more weeks before the completion date. It was further stated that the zone in trouble was said to be a smoke detector in the atrium area and that the fire alarm system was not compromised in its' current condition.
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Based on observations and confirmed by staff, the facility failed to ensure that portable fire extinguishers are maintained as required by NFPA 10. Section 4.4.1 requires fire extinguishers to be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection. Section 4.4.4 requires each fire extinguisher to have a tag or label securely attached that indicates the month and year the annual maintenance was performed and that identifies the person performing the service. Section 4.4.2.1 requires at the time of the annual maintenance, the tamper seal of rechargeable fire extinguishers be removed by operating the pull pin or locking device. After the applicable maintenance procedures are completed, a new tamper seal shall be installed.

THE FINDINGS INCLUDE:

6) During the morning hours of 8/9/12 the fire extinguisher located within the rehabilitation gym area was observed as being in the re-charge position.
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Based on observations and confirmed by staff, the facility failed to ensure that exit signs are properly placed. Section 7.10.2 states a sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

THE FINDINGS INCLUDE:

7) During the morning hours of 8/9/12 it was observed that the exit sign located in the rear corridor adjacent to the physical therapy suite directs travel back into the main lobby area. The sign should be pointing forward directing travel to the exit stairwell around the corner.
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These items were observed by hospital administration staff while touring the facility.

Based on observations, the facility failed to ensure that fume hoods are in accordance with NFPA 99. NFPA 99,Section 5.6.2 requires warning signs describing the nature of any hazardous effluent content to be posted at fume hoods' discharge points, access points, and filter locations. Warning signs should include, or reference, information on hazards, and on the changing, handling, and disposal of filters.

THE FINDINGS INCLUDE:

- Observations while touring the facility on the afternoon of 08/07/12 revealed that warning signs are not posted at the fume hood discharge points for exhaust fan # "REF 10".

This was observed by the Director of Facilities during the facility tour.

Based on observations and confirmed by staff, the facility failed to ensure compliance with chapter 19. Section 19.3.6.1 states corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. Section 19.3.6.3.1 states doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke.
Section 19.3.6.2.3 states fixed fire window assemblies in accordance with 8.2.3.2.2 shall be permitted in corridor walls.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 8/7/12 & 8/8/12, the following items were observed regarding corridor walls:

1) The radiology area "Pod 1" has numerous rooms (#'s 5; 6; 7; 8; 9; 10 and 11) open to the corridor. In addition, there are pass through windows in each of the x-ray rooms opening onto the corridor.
2) There are five (5) holding rooms open to the corridor in the radiology area.
3) The radiology waiting room is open to the corridor.
4) The Interventional Radiology area has four (4) holding rooms open to the corridor.
5) The Urology office is open to the corridor.
6) The 7th floor Med-room & staff Breakroom are equipped with tempered glass walls & doors. This smoke compartment is "partially sprinklered".
7) The 6th floor Med-room is equipped with tempered glass walls & door. This smoke compartment is "partially sprinklered".

Note: The plans provided by the hospital identified the above area's as utilizing corridors in lieu of suite designations. In addition, smoke detectors are not located in any of the above mentioned open area's and are spaced randomly throughout the main hospital corridors.

This was observed by hospital administration staff while touring the facility.

Based on observations and confirmed by staff, the facility failed to ensure compliance with chapter 19. Section 19.3.6.3 requires corridor doors other than vertical openings, exits or hazards areas to be 1-3/4" thick, solid-bonded core wood or of construction that resists fire for at least 20 minutes and shall be constructed to resist the passage of smoke. There shall be no impediment to closing the door, only approved hold open devices may be used.

THE FINDINGS INCLUDE:

- During the morning hours of 8/8/12 while touring the facility, it was observed that the doors to the patient bedrooms in the Medical Intensive Care Unit (MICU) do not latch. The doors are a sliding type that do not have latching devices.

This was observed by the Director of Facilities during the facility tour.

Based on observations and confirmed by staff, the facility failed to ensure that corridors doors are designed as required. Section 19.3.6.3.8 states fixed fire window assemblies in accordance with 8.2.3.2.2 shall be permitted in corridor doors.

THE FINDINGS INCLUDE:

- During the morning hours of 8/8/12 while touring the facility, it was observed that the doors & walls to the partially-sprinklered suite "G" and partially sprinklered seventh and sixth floor levels west and center wings are equipped with non-rated tempered glass.

This was observed by hospital administration staff while touring the facility.

Based on observations and confirmed by staff, the facility failed to ensure that smoke barrier doors are held open by approved devices. Section 19.2.2.2.6 states any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.
Section 7.2.1.8.2 states that in any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.
Section 2-10.6.2 states smoke detectors that are used exclusively for smoke door release service shall be located and spaced as required by 2-10.6. Section 2-10.6.5.1.1 states if the depth of wall section above the door is 24 in. (610 mm) or less, one ceiling-mounted detector shall be required on one side of the doorway only located at a maximum of five feet (5') from the door. Section 2-10.6.5.1.1 states if the wall section above the door is greater than twenty four inches (24") then a ceiling mounted detector is to be mounted on each side of the door way.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 8/7/12 & 8/8/12, it was observed that numerous smoke barrier doors are held open by magnetic devices. Upon further observations, it was noted that smoke detectors are not properly provided for the release of these smoke barrier doors. These include but are not limited to the following locations:

1) The double doors identified as 2-1168E leading into the Radiology area.
2) The double doors adjacent to room 7E09.
3) The 6th floor double doors identified as 6-023.
4) The door identified as 6E09.
5) The double doors identified as 5-024.
6) In the Clinic areas on the 5th, 6th, and 7th floor's there are doors located in two-hour fire rated walls being held open with devices that release upon activation of the fire alarm.

Note: The corridors are randomly equipped with smoke detectors mandating the requirement of smokes for individual door release.

This was observed by hospital administration staff while touring the facility.

Based on observations, plan review, and confirmed by staff, the facility failed to provide smoke barrier walls with a 1-hour fire rating assembly.

THE FINDINGS INCLUDE:

- During the morning hours of 8/8/12 while touring the facility, it was observed that the smoke barrier walls located by the Surgical Intensive Care Unit (SICU) are identified as 30-minute walls on the building floor plans. This was also substantiated during the building tour as it was observed that tempered glass (non-rated) transoms are used in various locations in the designated smoke walls.
Note: These walls are required smoke barrier walls in order to keep travel distances and smoke compartment sizes within the allowable parameters.

This was observed by hospital administration staff while touring the facility.

Based on observations and confirmed by staff, the facility failed to assure that hazardous area's are constructed/separated as required. Section 18.3.2.1 states any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated. Table 18.3.2.1 requires mechanical spaces to be enclosed with a minimum 1-hour fire rating wall assembly.

THE FINDING INCLUDE:

- During the morning hours of 8/8/12 while touring the facility, it was observed that the main mechanical room is not enclosed with the proper 1-hour rated assembly. The door leading into the mechanical space has a tempered glass transom panel which is non-rated.

This was observed by hospital administration staff while touring the facility.

Based on observations and confirmed by staff, the facility failed to ensure that stairwells are maintained as required:

THE FINDINGS INCLUDE:

- During the afternoon hours of 8/7/12, the following items were observed regarding stairwell doors:

1) Stair door #10 on the 4th floor level does not latch when fully closed.
2) Stair door #3 on the 2nd floor level does not latch when fully closed.
3) Stair door #5 on the 2nd floor level does not latch when fully closed.

Note: The hospital staff had the maintenance department immediately adjust these doors when brought to their attention.

This was observed by hospital administration staff while touring the facility.

Based on observations and confirmed by staff, the facility failed to ensure that maximum travel distances to exit egress locations are not exceeded. Section 18.2.6.2.1 states the travel distance between any room door required as an exit access and an exit shall not exceed 150 ft (45 m).
Section 18.2.6.2.2 states the travel distance between any point in a room and an exit shall not exceed 200 ft (60 m).
Section 18.2.6.2.4 states the travel distance between any point in a suite of sleeping rooms as permitted by 18.2.5 and an exit access door of that suite shall not exceed 100 ft (30 m) and shall meet the requirements of 18.2.6.2.2.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 8/8/12 while touring the facility, it was observed that the distances from the following locations were in excess of 200'.

1) The overall distance from the corner office in the anesthesia area is 260' to the exit by stair #2-0771 and 220' to the exit from the "J" corridor.

2) The overall distance from patient room #2E21 in the Surgical Intensive Care Unit (SICU) is 241' to exit adjacent to stair #13 and 218' to the 2-hour wall in the "J" corridor.

Note: The facility did have floor plans designating 2-hour wall locations for travel distances. However, when the walls were checked for integrity, it was observed that the walls were not 2-hour rated as noted.

This was observed by hospital administration staff while touring the facility.

Based on observations and confirmed by staff, the facility failed to ensure that maximum travel distances to exit egress locations are not exceeded. Section 19.2.6.2.1 states the travel distance between any room door required as an exit access and an exit shall not exceed 100 ft (30 m).
Exception: The maximum travel distance shall be permitted to be increased by 50 ft (15 m) in buildings protected throughout by an approved, supervised automatic sprinkler system.
Section 19.2.6.2.2 states the travel distance between any point in a room and an exit shall not exceed 150 ft (45 m).
Exception: The maximum travel distance shall be permitted to be increased by 50 ft (15 m) in buildings protected throughout by an approved, supervised automatic sprinkler system.
Section 19.2.6.2.4 states the travel distance between any point in a suite of sleeping rooms as permitted by 19.2.5 and an exit access door of that suite shall not exceed 100 ft (30 m) and shall meet the requirements of 19.2.6.2.2.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 8/8/12 while touring the facility, it was observed that the distances from the partially-sprinklered operating suites are all in excess of 100'. The travel distance is 175' to stair #2-0771 and 220' to the 2-hour rated "J" corridor exit door.

Note: The facility did have floor plans designating 2-hour wall locations for travel distances. However, when the walls were checked for integrity, it was observed that the walls were not 2-hour rated as noted.

This was observed by hospital administration staff while touring the facility.

Based on observations and confirmed by staff, horizontal exits are not maintained as required. Section 7.2.4.3.1 states 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.

THE FINDINGS INCLUDE:

- During the morning hours of 8/8/12 while touring the 2nd floor level Emergency Department (E.D.) Suite, the 2-hour fire rated barrier, separating the E.D. from the area outside the E.D., utilized by building tenants, was not properly constructed. H.V.A.C. ducts penetrating the barrier wall are not all equipped fire damper access doors.
This was noted from Exam Room #12 through Exam Room #14. The wall separates Exam Room #12 to a women's bathroom, Exam Room #14 to a corridor serving the Phlebotomy lab.
Without the H.V.A.C. access doors, verifying and servicing fire dampers is not possible.
This was observed by the Director of Facilities (D.O.F.) during the facility tour. The D.O.F said that reconstruction contractor's within the facility failed to identify these ducts and a facility vendor would be immediately called in to identify and remediate any fire damper deficiencies.

Based on observations and confirmed by staff, horizontal exits are not maintained as required. Section 7.2.4.3.1 states 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. Section 8.2.3.2.3.1 requires every opening in a fire barrier to 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 in a 2-hour fire barrier are required to have a 1-1/2-hour fire protection rating. NFPA 80, Section 2.1.4.1 requires self-closing doors to swing easily and freely and to be equipped with a closing device to cause the door to close and latch each time it is opened. Section 2.4.1.4 requires all closing mechanisms to be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

THE FINDINGS INCLUDE:

I. During the morning & afternoon hours of 8/6/12 and 8/7/12 while touring the facility, the following items were observed regarding 2-hour fire rated barrier doors. These include but are not limited to the following locations:

1) The door to the data closet identified as # 2J4.1 has a 20-minute fire rating label.
2) The door to the radiology conference room has a 20-minute fire rating label.
3) One of the double doors located by the central elevator currently drags on the floor and does not self close & latch.
4) Door # 2J-13.1 does not latch.
5) Door # 16 does not latch.
6) The 7th floor door # 7-023 does not latch.
7) Door # 6M-13 drags on the floor and does not self close & latch.
8) The 5th floor door # 5H 3.3 does not latch.
9) The 5th floor door # 5G-01 has a 3/8" gap between the door leaves.
10) The 7th floor door adjacent to # 7W01 does not latch.
11) The 7th floor door adjacent to # 7C01 does not latch.
12) The 7th floor door adjacent to # 7C38 does not latch.
13) The 6th floor door adjacent to # 6W36 does not latch.
14) The 5th floor door adjacent to # 5W36 had the closer arm disconnected.

II. During the morning & afternoon hours of 8/6/12 and 8/7/12 while touring the facility, the following items were observed regarding 2-hour fire rated barrier walls. These include but are not limited to the following locations:

The Emergency Department's 2-hour fire rated barrier wall between the "Family Consult" Room and patient sitting area has a 1" diameter void below the in-lay ceiling tiles. The void is in place to allow a wire cable to release via a fusible link in the event that the link releases.

These were observed by hospital administration staff while touring the facility. Hospital staff said that they were aware of the many door "problems" and that purchase orders were in place to replace and /or retro-fit door latching hardware.

Based on record review and confirmed by staff, it was revealed that the facility failed to ensure the fire alarm system is maintained as required. NFPA #72 (National Fire Alarm Code) section 7-1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request. Section 2-3.5.1 states smoke detectors shall not located in a direct airflow nor closer than three feet (3') from an air supply diffuser or return air opening.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 8/6/12 and 8/7/12 while touring the facility, the following items were observed regarding the maintenance & placement of smoke detectors. These include but not limited to the following locations:

1) The smoke detector in the operating-room storage room currently has a protective dust cap installed preventing the device from functioning as designed.
2) The smoke detector in the electrical closet 5G-09 currently has a protective dust cap installed preventing the device from functioning as designed.
3) Smoke detectors located at less than 3' from an air diffuser are as follows: 6th & 7th floor elevator #14/17 lobby's; by room # 7E05; by room # 6E26; by room 5H39 and by room 5-651.

This was observed by hospital administration staff while touring the facility.

Based on record review and confirmed by staff interview, the facility failed to ensure that the fire alarm system is maintained and tested as required. LSC Section 4.6.12.1 requires fire alarm systems to be continuously maintained in proper operating condition. NFPA 72, Section 7.3.2.1 requires smoke detector sensitivity to be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

THE FINDINGS INCLUDE:

- Records reviewed on the morning of 8/8/12 revealed that there was no documentation available substantiating that the sensitivity of smoke detectors has been checked as required in the Clinic areas.



This was observed by hospital administration staff while touring the facility.

Based on observations and confirmed by staff, the facility failed to ensure that non-sprinklered electrical rooms/closets are properly separated. NFPA 13 section 5-13.11 states that sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.
The exception states 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.
NFPA 101 Section 8.2.3.2.3.1 requires openings in 2-hour rated fire barriers to be protected by doors having at least a 90 minute fire protection rating.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 8/6/12 and 8/7/12 while touring the facility, it was observed that not all electrical closets are designed as required. These include but are not limited to the following locations:

1) The non-sprinklered electrical room # 7K-40 is equipped with a 20-minute rated door.
2) The non-sprinklered electrical room # 7K-18 is equipped with a 20-minute rated door.

This was observed by hospital administration staff while touring the facility.

Based on observations and confirmed by staff, the facility failed to ensure that all sprinkler control valves are properly supervised. Section 9.7.2.1 states 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 Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 8/8/12 it was observed that not all sprinkler valves are electronically supervised as required. These include but not limited to the following valves:

1) There are two Post Indicator Valves (PIV) that are not electronically supervised. These PIV's control the main water supply to the automatic sprinkler system for the facility. There is one located outside at the loading dock and the other is located outside of the Emergency Department.
Note: The wrench attached to the valve is currently padlocked.

2) The loading dock anti-freeze loop has three (3) sprinkler valves which are not supervised. These include one (1) outside stem and yolk (OS&Y) and two (2) butterfly type valves.

This was observed by the Director of Facilities during the facility tour.

Based on record review and observation, the facility failed to ensure that the automatic sprinkler system is maintained, tested and inspected as required by NFPA #25. Section 1.8 requires records of inspections, tests and maintenance of the system and components be kept and made available to the authority having jurisdiction. Section 1.8.1 requires records to indicate the procedure performed, the organization that performed the work, the results, and the date. Section 2.3.2 requires pressure gauges to be replaced or tested every 5 years. Section 2.2.1.1 requires sprinklers to be free of corrosion, foreign material, paint, and physical damage. Any sprinkler shall be replaced that is painted, corroded damaged, or loaded.

THE FINDINGS INCLUDE:

During the morning & afternoon hours of 8/8/12 while touring the hospital the following was observed:

1) The sprinkler pressure gauges at the following locations are dated 1977 and 1978: Standpipe #2, standpipe #4, standpipe # 5, standpipe #6, the main fire booster pump and main fire pump.

2) The recessed sprinkler heads in the main lobby and cafeteria area been painted.

This was observed by the Director of Facilities during the facility tour.

Based on observations, record review and confirmed by staff, the facility failed to ensure compliance with NFPA 90A. Section 3.3.1.1 requires approved fire dampers to be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more. Section 3.3.1.2 requires approved fire dampers to be provided in all air transfer openings in partitions that are required to have a fire resistance rating and in which other openings are required to be protected.
Section 2.3.4.1 requires a service opening to be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device. Section 2.3.4.2 requires service openings to be identified with letters having a minimum height of 1/2 in. to indicate the location of the fire protection device(s) within. Section 2.3.8 requires fire dampers to be installed in conformance with the conditions of their listings. Section 3.4.6.2 requires fire dampers, including their sleeves; smoke dampers; and ceiling dampers to be installed in accordance with the conditions of their listings and the manufacturer ' s installation instructions.

THE FINDINGS INCLUDE:

- During the morning & afternoon hours of 8/6/12 and 8/7/12 while touring the facility, the following ducts were observed penetrating 2-hour fire walls. The ducts noted below have no access panels to determine if fire dampers are in fact installed and/or maintained as required. These locations include but are not limited to the following locations:

1) Above the Trump connector door there is a 16" x 12" duct.
2) Above door #2-003 there are two (2) 10" x 10" ducts.
3) Above the radiology conference room there is a 16" x 12" duct.
4) Above the Post Anesthesia Care Unit (PACU) nurse's locker room wall there is a 12" x 10" duct.
5) Above the cross corridor wall by stair #10 there is a 24" x 12" duct.

This was observed by hospital administration staff while touring the facility.

Based on observations during the building tour and confirmed by staff, the facility failed to ensure compliance with the restrictions of portable space heating devices. Section 9.7.8 states portable space-heating devices shall be prohibited in all health care occupancies.

THE FINDING INCLUDE:

- During the morning & afternoon hours of 8/6/12 and 8/7/12 while touring the facility, portable space heaters were observed but not limited to the following locations:.

1) The office within the facility's management department.
2) The liver transplant office room #4E44.
3) The nursing office identified as 6K-06.
4) The office identified as 5G-10.5.

Note: These were all immediately removed when brought to the hospital staff's attention.

Based on observations and confirmed by staff, the facility failed to ensure proper separation from the adjacent dialysis unit by a 1-hour fire separation. Section 6.1.14.2 states where a mixed occupancy classification occurs, the means of egress facilities, construction, protection, and other safeguards shall comply with the most restrictive life safety requirements of the occupancies involved. Section 21.1.2.1 states sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
(1) They are not intended to serve ambulatory health care occupants for purposes of treatment or customary access by patients incapable of self-preservation.
(2) They are separated from areas of ambulatory health care occupancies by construction having a fire resistance rating of not less than 1 hour.

THE FINDINGS INCLUDE:

1) During the morning hours of 8/9/12 while touring the facility, it was observed that the wall above the dialysis door has a 16" x 3' and a 2' x 3' piece of drywall missing.
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Based on observations and confirmed by staff, the facility failed to ensure that stairwells are properly maintained as required. Section 8.2.5.2 states openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier. Section
8.2.5.4 states the fire resistance rating for the enclosure of floor openings shall be not less than as follows (see 7.1.3.2.1 for enclosure of exits):
(3) Existing enclosures in existing buildings - 1/2-hour fire barriers

THE FINDINGS INCLUDE:

2) During the morning hours of 8/9/12 while touring the facility, it was observed that the front stairwell (required) is lacking self closing devices on three of the top landing level doors.
3) During the morning hours of 8/9/12 while touring the facility, it was observed that the top door of the rear stairwell (required) does not latch when in the closed position.
********************

Based on observations and confirmed by staff, the facility failed to ensure that sprinkler heads are installed as required. NFPA 13 section 5-6.4.1.1 states 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).

THE FINDINGS INCLUDE:

4) During the morning hours of 8/9/12 while touring the facility, it was observed that the sprinklered electric room is missing approximately twelve (12) ceiling tiles. The sprinkler heads are currently located 4' below the deck above.
********************

These items were observed by hospital administration staff while touring the facility.

Based on observations, record review, and confirmed by staff, the facility failed to ensure that sprinkler systems are maintained as required. NFPA 25 section 2-3.3 states waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly. Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector's test connection which simulates activation of a sprinkler head. Section 2-3.2 states gauges on sprinkler systems shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. Section 2.2.1.1 requires sprinklers to be free of corrosion, foreign material, paint, and physical damage. Any sprinkler shall be replaced that is painted, corroded damaged, or loaded.

THE FINDINGS INCLUDE:

- During the morning hours of 8/9/12 the following items were observed regarding the sprinkler system:

1) The sprinkler system is only inspected/tested one time per calendar year.
2) The sprinkler gauges are dated 1989 & 2003.
3) The recessed sprinkler heads in the atrium area have all been recently painted.
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Based on observations and confirmed by staff, the facility failed to ensure that exit stairs are maintained as required. Section 7.2.2.5.3 states there shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.

THE FINDINGS INCLUDE:

4) During the morning hours of 8/9/12 a total of five (5) large trash carts were observed as being stored in the rear stairwell.
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Based on record review and confirmed by staff, it was revealed that the facility failed to ensure the fire alarm system is maintained as required. NFPA #72 (National Fire Alarm Code) section 7-1.2 states the owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

THE FINDINGS INCLUDE:

5) During the morning hours of 8/9/12 upon entering the building, the main fire alarm panel was observed as being in the "trouble" mode. When the building maintenance director was asked about this condition, he acknowledged that he was aware of the trouble situation. It was further stated that the building was under renovations (mainly cosmetics) and that the repair would not be made until all the work was completed. The work had been going on for approximately a couple of weeks and was slated for approximately two more weeks before the completion date. It was further stated that the zone in trouble was said to be a smoke detector in the atrium area and that the fire alarm system was not compromised in its' current condition.
********************

Based on observations and confirmed by staff, the facility failed to ensure that portable fire extinguishers are maintained as required by NFPA 10. Section 4.4.1 requires fire extinguishers to be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection. Section 4.4.4 requires each fire extinguisher to have a tag or label securely attached that indicates the month and year the annual maintenance was performed and that identifies the person performing the service. Section 4.4.2.1 requires at the time of the annual maintenance, the tamper seal of rechargeable fire extinguishers be removed by operating the pull pin or locking device. After the applicable maintenance procedures are completed, a new tamper seal shall be installed.

THE FINDINGS INCLUDE:

6) During the morning hours of 8/9/12 the fire extinguisher located within the rehabilitation gym area was observed as being in the re-charge position.
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Based on observations and confirmed by staff, the facility failed to ensure that exit signs are properly placed. Section 7.10.2 states a sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

THE FINDINGS INCLUDE:

7) During the morning hours of 8/9/12 it was observed that the exit sign located in the rear corridor adjacent to the physical therapy suite directs travel back into the main lobby area. The sign should be pointing forward directing travel to the exit stairwell around the corner.
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These items were observed by hospital administration staff while touring the facility.